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PHYSICAL DIAGNOSIS 



PHYSICAL DIAGNOSIS 



BY 

W. D. ROSE, M.D., 

Lecturer on Physical Diagnosis and Associate Professor of Medicine in tli 
University of Arkansas; Demonstrator of Clinical Medicine and Chief 
of the Medical Section of the Isaac Folsom Clinic ; Visiting 
Physician Logan H. Roots Memorial (City) Hos- 
pital, Little Rock, Arkansas 



SECOND EDITION 



THREE HUNDRED NINE ILLUSTRATIONS 



ST. LOUIS 

C. V. MOSBY COMPANY 

1921 






Copyright, 1917, 1921, By C. V. Mosby Company 
(All rights reserved) 



Printed in U. S. A. 



Press of 

..,., C. V. Mosby Company 

JUN !U l^?l St. Louis 



©CU617290 



DEDICATED TO 

MORGAN SMITH, M.D., LL.D. 

DEAN OF THE MEDICAL DEPARTMENT 

OF THE 

UNIVERSITY OF ARKANSAS 



PREFACE TO SECOND EDITION 



The exhaustion of the present edition and the persistent de- 
mand for the book are the incentives for this revision, in the 
preparation of which the author has availed himself of the sug- 
gestions contained in the kindly criticisms of the reviewers of 
the original edition of the work. 

In the preparation of the present volume the text has been 
largely rewritten and supplemented by new material in order to 
cover the recent advances in the subject. The clinical anatomy 
of the various thoracic and abdominal organs has been carried a 
step further in this edition, and the intimate correlation of 
anatomy, pathology, and physical signs has been emphasized 
throughout the text. Additional space has likewise been allotted 
in the present edition to the physical principles underlying the 
various physical signs which are generated within the thorax and 
abdomen in health and in disease. 

In the present edition, many of the borrowed illustrations of the 
first edition have been replaced by original drawings. 

The chapter dealing with the x-ray as an aid in diagnosis has 
been revised and amplified by Dr. Dudley E. Mackey, of New 
York, formerly Instructor in Roentgenology, Cornell School of 
Military Roentgenology. 

W. D. R. 

Little Eock, Ark. 



PREFACE TO FIRST EDITION 



In the preparation of this volume the author has had in mind 
the medical student and the busy practitioner, and it has been 
his purpose to incorporate in a brief work the principles of 
physical diagnosis, together with the physical findings in, the 
commoner diseases of the respiratory and circulatory systems. 
In this connection anatomy and pathology have been considered 
from the clinical standpoint, emphasis being laid upon these 
subjects as they influence the physical manifestations of disease 
of the thorax and abdomen. 

In addition to the physical examination of the thoracic and 
abdominal viscera, it has seemed proper and practical to in- 
clude in the work the principal diagnostic signs referable to 
the head, neck, and limbs, together with a minimum examina- 
tion of the nervous system. 

The work has been profusely illustrated, in the belief that 
free illustration is the nearest approach to personal contact in 
the teaching clinic. 

The author wishes to express his appreciation to Dr. C. E. 
Shinkle, whose diagnostic table on the Barany Tests is repro- 
duced in the volume, for valuable assistance in preparing the 
section dealing with these tests. Many illustrations have been 
taken from other books, all of which have been credited in the 
text. He also wishes to thank Mrs. T. W. Marks for assistance 
rendered in the preparation of original drawings for the text; 
and the publishers for many courtesies during the preparation 
and publication of the volume. 

W. D. EosE. 

Little Eock, Ark. 



CONTENTS 



PART I— THE THORAX 

SECTION I 
Chapter I — Clinical Anatomy of the Thorax 
Clinical Anatomy of the Thorax, 25. 

SECTION II 
PHYSICAL EXAMINATION OF THE EESPIEATORY ORGANS 

Chapter II — Inspection 

Inspection, 52; The Chest Wall, 53; The Size and Shape of the Thorax, 
56 ; The Normal Thorax, 56 ; Deformities of the Thorax, 59. 

Chapter III — Palpation 

Palpation, 86 ; Thoracic Vibrations, 89 ; Vocal Fremitus, 89 ; Pathologic 
Variations, 98 ; Rhonchal Fremitus, 102 ; Pleural Friction Fremitus, 103 ; 
Tussile Fremitus, 104; Succussion Fremitus, 104; Hydatid Fremitus, 105; 
Crepitation, 105 ; Local Tenderness, 105 ; The Intercostal Spaces, 107 ; The 
Ribs and Sternum, 107; Local Pulsation, 108; Fluctuation, 109. 

Chapter IV — Percussion 

Percussion, 111 ; Palpatory Percussion, 115 ; Auscultatory Percussion, 116 * 
Respiratory Percussion, 117 ; Superficial and Deep Percussion, 117 ; Attributes 
of the Percussion Sound, 118 ; Degree of Resistance, 118 ; Normal Percussion 
Sounds, 119 ; The Respiratory Excursion of the Lung, 125 ; Abnormal Per- 
cussion Sounds, 126 ; Tympany, 130 ; Wintrich 's Cliange of Sound, 135 ; Wint- 
rich's Interrupted Change of Sound, 135; Freidreich's Respiratory Change of 
Sound, 137; Gerhardt's Change of Sound, 138; Biermer's Phenomenon, 139; 
Skodiac Resonance, 139 ; Williams ' Tracheal Tone, 141 ; Amphoric Resonance, 
141; The Cracked-Pot Sound (Bruit de pot fele; Monev-C'hink Resonance), 
142; Gairdner's Coin Test (Bell Tympany; Anvil Test), 144. 

Chapter V — Auscultation 

Auscultation, 145; Normal Respiratory Sounds, 148; Abnormal Respiratory 
Sounds, 153 ; Vocal Resonance, 155 ; Pathologic Variations, 156 ; Modified 
Vocal Resonance, 158; Adventitious Sounds, 159; Rales, 159; The Metallic 
Tinkle (Gutta Cadens ; Falling-drop Sound), 167; Hippocratic Succussion 
(Splashing Sound), 168; The Pleural Friction Sound, 169; The Lung-Fistula 
Sound, 171. 

Chapter VI — Thoracometry, Cyrtometry, and Thoracentesis 
Thoracometry, Cyrtometry, and Thoracentesis, 173. 

Chapter VII — Radiographic Diagnosis (By Dudley E. Mackey, B. S., M.D., 

New York) 

Radiographic Diagnosis, 176; Bones and Joints, 176; The Long Bones, 
184; Arthritis, 186; The Head, 187; The Thorax, 188; The Urinary Tract, 
201; The Gastrointestinal Tract, 203. 

11 



12 CONTENTS 

SECTION III . 

DISEASES OF THE EESPIKATORY ORGANS 

Chapter VIII — Diseases of the Bronchi 

Diseases of the Bronchi, 205 ; Acute Bronchitis, 205 ; Chronic Bronchitis, 
207; Fibrinous Eronchitis, 212; Bronchiectasis, 214; Bronchial Asthma, 219; 
Tracheobronchial Stenosis, 224. 

Chapter IX — Circulatory Disturp>ances of the Lungs 

Circulatory Disturbances of the Lungs, 226; Pulmonary Congestion (Con- 
gestion of the Lungs), 226; Pulmonary Edema (Edema of the Lungs), 227; 
Pulmonary Infarction, 229. 

Chapter X — Diseases of the Lungs 

Diseases of the Lungs, 232; Lobar Pneumonia (Croupous, or Fibrinous 
Pneumonia), 232; Bronhcopneumonia (Lobular or Catarrhal Pneumonia), 240; 
Chronic Interstitial Pneumonia (Productive Pneumonia; Cirrhosis or Fibrosis 
of the Lung), 245; Tuberculosis of the Lungs, 249; Acute Miliary Tuberculosis 
of the Lungs, 251; Acute Pneumonic Phthisis, 252; Acute Bronchopneumonic 
Phthisis, 254; Chronic Ulcerative Phthisis, 255; Fibroid Phthisis, 264; Pul- 
monary Syphilis, 266; Pneumonokoniosis, 268; Atelectasis, 272; Hypertrophic 
Emphysema, 274; Atrophic Emphysema, 278; Compensatory Emphysema, 279; 
Acute Vesicular Emphysema, 281 ; Interstitial Emphysema, 282 ; Abscess of 
the Lung, 283; Gangrene of the Lung, 289; Tumors of the Lung, 295. 

Chapter XI — -Diseases of the Pleura 

Diseases of the Pleura, 297; Acute Fibrinous Pleurisy (Acute Plastic Pleu- 
risy; Pleuritis Sicca), 297; Serofibrinous Pleurisy (Pleurisy with Effusion, 
Pleuritis Exudativa), 299; Local Pleurisy, 306; Diaphragmatic Pleurisy, 306; 
Loculated, Sacculated, or Encysted Pleurisy, 307; Interlobar Pleurisy, 307; 
Purulent Pleurisy (Empyema), 308; Chronic Adhesive Pleurisy, 311; Hemo- 
thorax, 313; Chylothorax, 313;' Hydrothorax, 313; Pneumothorax (Hydro-, 
Hemo-, or Pyo-Pneumothorax), 314. 

SECTION IV 
PHYSICAL EXAMINATION OF THE CIRCLLATORY ORGANS 

Chapter XII — Clinical Anatomy 

Clinical Anatomy, 317; The Heart, 317; The Cardiac Valves, 320; The 
Bundle of His, 321; The Pericardium, 321; The Aorta, 322; Tlie Pulmonary 
Artery, 324; Topographical Anatomy, 324. 

Chapter XIII — Inspection 

Inspection, 327; Precordial Bulging, 327; Precordial Retraction, 328; Ab- 
normal Areas of Pulsation, 328 ; The Venous Pulse, 332 ; The Centripetal 
Venous Pulse, 333; Thoracic Retraction (Broadbent's Sign), 333; The Cardiac 
Impulse (Apex Beat), 334; Displacement of the Cardiac Impulse, 336; Varia- 
tions in the Area of the Cardiac Impulse, 339; Variations in the Force of the 
Cardiac Impulse, 340; Double Impulse, 340; Systolic Recession, 341; Capillary 
Pulsation (The Capillary Pulse), 341. 

Chapter XIV — Palpation 

Palpation, 343 ; Valve Shock, 343 ; Pericardial Friction Fremitus, 344 ; 
Thrills, 344; The Cardiac Impulse, 346; The Pulse, 346; Technic of Taking 
the Pulse, 346 ; The Sphygmographic Tracing, 349 ; Variations in the Sphygmo- 
gram, 350 ; Changes in the Artery, 350 ; Analysis of the Pulse, 350. 



CONTEXTS 13 

Chapter XV — Percussiox 

Percussion, 359 ; Technic of Cardiac Percussion, 361 ; A^ariations in the 
Areas of Cardiac Dullness, 361 ; Vascular Dullness, 365. 

Chapter XVI — Auscultatiox 

Auscultation, 366 ; Tlie Xormal Heart Sounds, 366 ; Auscultatory Valve 
Areas, 367 ; Variations in Intensity of the Cardiac Sounds, 368 ; Eeduplication 
of the Heart Sounds, 371; Cardiac Arrhythmia, 372; Adventitious Sounds, 
380 ; Endocardial Murmurs, 380 ; Characteristics of Endocardial Murmurs, 381 ; 
Mitral Murmurs, 383 ; Pulmonary Murmurs, 389 ; Functional Murmurs, 390 ; 
Multiple Murmurs and Their Diagnosis, 391 ; Cardiorespiratory Murmur, 392 ; 
Pericardial Friction, 393 ; Pericardial Succussion Sound, 393 ; Vascular Mur- 
murs, 394; Arterial Murmurs, 394; Venous Murmurs, 395; Blood Pressure, 396. 



SECTTOX V 
DISEASES OF THE CIECX^LATOEY OEGAX^S 

Chapter XVII — Diseases of the Pericardium 

Diseases of the Pericardium, 407; Pericarditis, 407; Acute Fibrinous Peri- 
carditis (Pericarditis Sicca), 407; Serofibrinous Pericarditis (Pericarditis 
with Effusion; Pericarditis Exudativa), 410; Chronic Adhesive Pericarditis, 
413; Hydropericardium (Hydrops Pericardii), 416; Hemopericardium, 416; 
Pneumopericardium (Hydro-, Hemo-, or P'yo-Pneumopericardium), 416. 

Chapter XVIII — Diseases or theExdocardium and Valves 

Diseases of the Endocardium and Valves, 418; Acute Endocarditis, 418; 
Chronic Endocarditis, 421 ; Chronic Valvular Disease, 423 ; Aortic Eegurgita- 
tion (Aortic Insufiicieney ; Aortic Incompetence; Corrigan's Disease), 425; 
Aortic Stenosis, 434; Mitral Eegurgitation (Mitral Insufficiency; Mitral In- 
competence), 441; Mitral Stenosis, 451; Pulmonary Eegurgitation (Pulmonary 
Insufficiency; Pulmonary Incompetence), 457; Pulmonary Stenosis, 459; Tri- 
cuspid Eegurgitation (Tricuspid Insufficiency; Tricuspid Incompetence), 462; 
Tricusi^id Stenosis, 465. 

Chapter XIX — Diseases of the Myocardium 

Diseases of the Myocardium, 467 ; Acute Myocarditis (Acute Myocardial 
Degeneration), 467; Chronic Myocarditis (Chronic Fibrous Myocarditis; 
Chronic Interstitial Myocarditis), 469; Cardiac Hypertrophy, 470; Left Ven- 
tricular Hypertrophy, 472 ; Eight Ventricular Hypertrophy, 473 ; Left Auricu- 
lar Hypertrophy, 473 ; Eight Auricular Hypertrophy, 473 ; Cardiac Dilatation, 
474; Congenital Heart Disease, 478; Aneurysm of the Aorta, 480. 



PART II— THE ABDOMEN 

SECTIOX I 
GEXEEAL EXAMIXATIOX OF THE ABDOMEX 

Chapter XX — Clixical Axatomy of the Abdomex 

Clinical Anatomy of the Abdonien_, 485 ; Anatomical Landmarks of the Ab- 
domen, 486; Topographical Anatomy, 489; Topographical Eegions of the Ab- 
domen, 490. 



14 CONTENTS 

■ * 
Chapter XXI — Inspection of the Abdomen 

Inspection of the Abdomen, 495; The Skin of the Abdomen, 495; Enlarge- 
ment of the Superficial Veins of the Abdomen, 496; The Umbilicus, 496; En- 
larged Glands, 498 ; Visible Peristalsis, 499 ; Abolition of the Eespiratory 
Movements of the Abdomen, 501 ; Variations in the Contour of the Abdomen, 
501; Obesity, 501; Pregnancy, 501; Meteorism, 503; Ascites, 503; Viscerop- 
tosis, 506; Asymmetrical Variations, 509; Abdominal Eetraction, 510. 

Chapter XXII — Palpation, Percussion, Auscultation, and Mensuration 

OF Abdomen 

Palpation, 511; Percussion, 516; Auscultation, 517; Mensuration, 518. 

SECTION II 
SPECIAL EXAMINATION OF THE ABDOMINAL VISCERA 

Chapter XXIII — The Stomach, Intestines, and Pancreas 

Examination of the Stomach, 520 ; Examination of the Small Intestine, 
532 ; Examination of the Large Intestine, 535 ; Examination of the Pancreas, 
544. 

Chapter XXIV — Examination of the Liver and Gall Bladder 

Examination of the Liver and Gall Bladder, 549. 

Chapter XXV — Examination of the Spleen, Kidneys, Bladder and 

Ureters 

Examination of the Spleen, 570; Examination of the Kidneys, 583; Exam- 
ination of the Bladder, 596; Examination of the Ureters, 597. 



PART III— THE HEAD, NECK, AND EXTREMITIES 

SECTION I 

THE HEAD AND NECK 

Chapter XXVI — Examination of the Head 
Examination of the Head, 599. 

Chapter XXVII — ^Examination of the Face 

Contour of the Face, 605 ; The Color of the Face, 609 ; Spasm of the Face, 
610; The Forehead, 611; The Eyes, 611; The Nose, 614; The Lips, 616; The 
Breath, 620; The Teeth, 620; The Gums, 621; The Tongue, 621; The Buccal 
Cavity, 626; The Pharynx, 627; The Tonsils, 627. 

Chapter XXVIII — Examination of the Neck 
Examination of the Neck, 629. 

SECTION II 
EXAMINATION OF THE HAND AND ARM 

Chapter XXIX — The Hand 

The Nails, 636; The Fingers, 638; Shape of the Hand, 641 ; Tremor of 
the Hand, 644. 

Chapter XXX — The Forearm and Arm 
Examination of the Forearm, 647; Examination of the Arm, 647. 



CONTENTS 15 

SECTION III 

EXAMINATION OF THE LOWEE EXTEEMITIES 

Chapter XXXI — The Foot, Leg, and Thigh 
The Toes, 650; The Foot, 650; The Leg, 651; The Thigh, 653. 

PART IV— EXAMINATION OF THE NERVOUS SYSTEM 

SECTION I 

MOTOE AND SENSOEY PHENOMENA 

Chapter XXXII — Station, Gait, and Muscular Power — Tremor 
Station, Gait, and Muscular Power — Tremor, 657. 

Chapter XXXIII — Sensory Phenomena — The Eeflexes 
Sensory Phenomena — The Eeflexes, 663. 

Chapter XXXIV — The Cranial Nerves 

The Olfactory Nerve, 673; The Optic Nerve, 674; The Third, Fourth, and 
SLxth Cranial Nerves, 678 ; Trigeminal Nerve, 681 ; The Facial Nerve, 682 ; The 
Auditory Nerve, 684 ; The Barany Tests, 685 ; The Glossopharyngeal Nerve, 
696; The Pneumogastric Nerve, 696; The Spinal Accessory Nerve, 697; The 
Hypoglossal Nerve, 697. 

APPENDIX 
Appendix, 698; Case History, 698. 



ILLUSTRATIONS 



FIG. PAGE 

1. Eelations and surface markings of thoracic and abdominal viscera. 

(Anterior view.) 26 

2. Eelations and surface markings of thoracic and abdominal viscera. 

(Posterior view.) 27 

3. Eelations of the lungs with the anterior thoracic wall 29 

4. The Bronchial tree 32 

5. Pulmonary capillaries 38 

6. Illustrating the normal borders of the lungs and the location of the 

interlobular septa. (Anterior view.) 40 

7. Illustrating normal borders of the lungs and interlobular septa. (Pos- 

terior view) 41 

8. Illustrating the normal borders of the lungs and the location of the 

interlobular septa. (Lateral view.) 42 

9. Showing the position of the bifurcation of the trachea and the peri- 

tracheal and peri-bronchial glands projected upon the anterior 

surface of the chest in a young adult 43 

10. Showing the position of the bifurcation of the trachea with the peri- 

tracheal and peri-bronchial glands projected upon the posterior 

surface of the chest in a young adult 43 

11. Topographic regions of the thorax. (Anterior view.) 47 

12. Topographic regions of the thorax. (Posterior view.) 48 

13. Normal thorax (in repose) 57 

14. Normal thorax (full inspiration) 58 

15. Normal thorax (full expiration) 59 

16. Cross section of normal thorax , 59 

17. Emphysemic chest. (Front view.) 61 

18. Emphysemic chest. (Lateral view.) 62 

19. Cross section of emphysematous thorax 63 

20. Phthisical thorax 64 

21. Phthisical thorax. (Anterior view.) 65 

22. Phthisical thorax. (Lateral view.) 66 

23. Phthisical thorax. (Posterior view.) 67 

24. Cross section of rachitic thorax 68 

25. Cross section of pigeon breast 68 

26. Kyphosis due to vertebral caries . 69 

27. Illustrating the movements of the diaphragm and thoracic and ab- 

dominal walls, as well as the change in position of the intra- 
thoracic and intraabdominal viscera, during respiration of the 

abdominal type 73 

28. Showing the movements of the diapliragm and thoracic and abdominal 

walls, as well as the change in position of the intrathoracic and 
intraabdominal viscera, when combined thoracic and abdominal 

breathing are pronounced 74 

29. Cheyne-Stokes respiration 78 

30. Palpation of anterior thoracic surface 86 

31. Ulnar palpation of thorax 86 

32. Palpation of upper anterior thorax 87 

33. Palpation of pulmonary apices 87 

34. Detection of lagging at apices 87 

35. Detection of lagging at pulmonary bases 87 

36. Linear palpation of thorax 88 

17 



18 ILLUSTRATIONS 

FIG. * PAGE 

37. Palpation of the intercostal spaces 88 

38. Normal variations in vocal fremitus 90 

39. Normal variations in vocal fremitus 91 

40A. Illustrating the importance of variations in the thickness of the 

thoracic wall upon the interpretation of physical findings upon 

palpation of the thorax 92 

40B. Section through body 6 cm. to the right of the median plane, view 
from the right. Showing the importance of the soft tissues as 

influencing physical examination of different areas of the chest 93 

40C. Section through body 6 cm. to the left of the median plane viewed 
from the right. Showing the importance of the soft tissues as 

influencing physical examination of different areas of the chest 95 

41. Percussion hammer 112 

42. Hard rubber pleximeter 112 

43. Immediate percussion of clavicle 113 

44. Immediate percussion of pulmonary bases 113 

45. Percussion of pulmonary apices 114 

46. Percussion of lateral thoracic region 114 

47. Percussion of posterior thorax 114 

48. Auscultatory percussion 116 

49. Limitation of pulmonary resonance of apices 124 

50^. Areas of dullness in apical pulmonary tuberculosis 126 

50B. Areas of dullness in apical pulmonary tuberculosis 126 

51. Physical causes of change in percussion note 127 

52^. Area of dullness in moderate pleural effusion 128 

52B. Area of dullness in moderate pleural effusion 128 

5?,A. Percussion findings in serofibrinous pleurisy with effusion .... 128 

535. Percussion findings in serofibrinous pleurisy with effusion . . . 128 

54^. Dullness of aortic aneurysm 129 

54:B. Dullness of aortic aneurysm 129 

55. Physical causes of change in percussion note 131 

56. Physical basis of pathologic physical signs upon percussion and aus- 

cultation of the thorax 133 

57^. Illustrating the physical basis of Wintrich's interrupted change of 

sound 136 

57B. Illustrating the physical basis of Wintrich's interrupted change of 

sound 137 

58^. Illustrating the physical basis of Gerhardt's change of sound . . 138 

58B. Illustrating the physical basis of Gerhardt's change of sound . . 139 

59. Illustrating Bell tympany, or Gairdner's coin test 144 

60. Hawksley 's monaural stethoscope 146 

61. Bowles' stethoscope . 146 

62. Binaural stethoscope 146 

63. Auscultation of thorax 147 

64. Normal distribution of bronchial and bronchovesicular breathing. 

Anterior thoracic surface 148 

65. Normal distribution of bronchial and bronchovesicular breathing. 

Posterior thoracic surface 149 

06. Physical basis of pathologic physical signs upon percussion and aus- 
cultation of the thorax 150 

67. Illustrating the physical basis of pathologic physical signs upon 

auscultation of the thorax 160 

68. Usual site of pleural friction sound 169 

69. Potain's aspirator 174 

70. Compound-comminuted fractures of phalanges and metacarpal of hand 177 

71. Stellate fracture of great trochanter of femur ........ 178 

72. Impacted fracture of head of humerus with separation and displace- 

ment of head 179 

73. Depressed fracture of the skull 180 

74. Linear fracture of the vault. Stellate in type 181 



ILLUSTRATIONS 19 

FIG. PAGE 

75. Linear fracture of the skull involving the frontal sinus .... 182 

76. Accessory sinus. Frontals clear, ethmoids clear, and antrum clear . 182 

77. Absence of frontal sinus 183 

78. Large frontal sinus. Eight antrum cloudy 184 

79. Frontal sinus clear, ethmoids clear, both antra cloudy 185 

80. Absence of one frontal sinus. Ethmoids clear, both antra cloudy . 186 

81. Sella turcica well defined — normal sphenoidal sinus clear .... 187 

82. Mastoid cells normal. Large type 188 

83. Apical abscess 189 

84. Old unextracted root 190 

85. Unerupted teeth. Early life 190 

86. Unerupted molar. Adult 191 

87. Impacted molar 192 

88. Unerupted canine 193 

89. Normal heart diagram method of estimating size by use of radio- 

graph , 194 

90. Normal stomach — normal cap 195 

91. Penetrating ulcer of lesser curvature 195 

92. Hourglass stomach 196 

93. Appendix visible 197 

94. Normal kidney 198 

95. Lijected sinus . 199 

96. Calculi in bladder 200 

97. Calculi in bladder 201 

98. Calculus after removal 202 

99. Encapsulated empyema. Eight 202 

100. Tuberculosis of the chest with typical drop heart 203 

101. Tuberculosis of the lung 204 

102. Sacculated bronchiectasis 216 

103. Curschmann's Spirals 220 

104. Eosinophiles. A considerable percentage of the pus cells of asth- 

matic sputum are eosinophiles. This is probably indicative of 

chronic intoxication 220 

105. Charcot-Leyden crystals. These crystals are formed in sputum of 

chronic bronchitis, especially if asthma exists 222 

106. Consolidation of bronchopneumonia 241 

107. Interstitial pneumonia with emphysema . 246 

108. Illustrating caseous tuberculosis. Large cavities at the apex and 

many small cavities throughout the lung 253 

109. Illustrating pulmonary tuberculosis, with thickened pleura, many 

bronchiectatic cavities, and generalized cavity formation . . . 256 

110. Eoentgenogram. The special features of this picture are the prom- 

inent bronchi, showing induration; the diffuse shadows through- 
out the lungs, indicating tuberculosis; small tent-like raised areas 
in the diaphragm, indicating pleural adhesions and the large 

right heart 258 

111. Lung. Chronic phthisis, showing a large irregular cavity in the 

upper lobe. In the loAver lobe there are scattered acute nodules 
grouped in clusters around the small bronchi ; and also several 

small more acute cavities 259 

112. Illustrating compensatory change in right lung with depression of 

the diaphragm following extensive cavitation of left lung . . 260 

113. Pneumonia alba of newborn 267 

114. Anthrocosis 269 

115. Pulmonary capillaries 275 

116. Cardiac displacement as result of compensatory emphysema of the 

right lung following sclerosis of left lung 280 

117. Eolation of chambers of unopened heart to anterior thoracic wall . 325 

118^. Site of normal cardiac impulse 335 

118B. Site of normal cardiac impulse 335 



20 ILLUSTRATIONS 

FIG. * PAGE 

119. Illustrating moderate displacement of the heart toward the left in 

compensatory emphysema of the right lung, with elevation of the 
left vault of the diaphragm and displacement toward the left 

of the structures in the median line of the neck 338 

120. Illustrating cardiac displacement toward the right in compensatory 

emphysema of the left lung, which is attended by depression of 
the diaphragm upon the left side and by displacement of the 

structures of the median line of the neck toward the right side 338 

121. Demonstration of capillary pulse . . 341 

122 A. Sites of palpable thrills and pericardial friction fremitus . . . 345 

122B. Sites of palpable thrills and pericardial friction fremitus . . . 345 

123. Palpation of cardiac impulse (first maneuver) 347 

124. Palpation of cardiac impulse (second maneuver) 347 

125. Palpation of cardiac impulse (third maneuver) 348 

126. Palpation of the radial pulse 348 

127. Normal sphygmogram 349 

128. Sphygmograms of pathologic types of pulse 353 

129. Sphygmograms of jDathologic types of pulse 355 

130. Method of detection of water-hammer pulse 357 

131. Testing the symmetry of the radial pulses 357 

132. Areas of cardiac and hepatic dullness and flatness 360 

133. Extension of cardiac dullness toward the right and toward the left 

and downward in combined right and left ventricular hyper- 
trophy 362 

134. General extension of cardiac dullness in extensive pericardial effusion 363 

135. Extension of cardial dullness toward the left and downward in left 

ventricular hypertrophy 364 

136. Extension of cardiac dullness toward the right in right ventricular 

hypertrophy 364 

137^. Auscultatory valve areas of the heart 367 

1375. Auscultatory valve areas of the heart 367 

138. Sound chart 369 

139. Same as Fig 138 369 

140. Same as Fig. 138 370 

141. Same as Fig. 138 370 

142. Same as Fig. 138 371 

143. Same as Fig. 138 372 

144. Illustrating the physical basis of murmurs generated by diminution 

of lumen 381 

145^. Point of maximum intensity of mitral presystolic murmur . . . 383 

1455. Point of maximum intensity of mitral presystolic murmur . . 383 
146^. Point of maximum intensity and line of transmission of mitral 

systolic murmur 385 

1465. Point of maximum intensity and line of transmission of mitral 

systolic murmur 385 

147^. Point of maximum intensity and line of transmission of aortic 

systolic murmur 386 

1475. Point of maximum intensity and line of transmission of aortic 

systolic murmur 386 

148J. Points of maximum intensity and lines of transmission of aortic 

diastolic murmur 387 

1485. Points of maximum intensity and lines of transmission of aortic 

diastolic murmur 387 

14:9A. Point of maximum intensity of tricuspid presystolic murmur . . 388 

1495. Point of maximum intensity of tricuspid presystolic murmur . . 388 
150^. Point of maximum intensity and line of transmission of tricuspid 

systolic murmur 389 

1505. Point of maximum intensity and line of transmission of tricuspid 

systolic murmur 389 



ILLUSTRATIONS 21 

FIG. PAGE 

151^. Point of maximum intensity and line of transmission of pulmonary 

systolic murmur . 390 

1515. Point of maximum intensity and line of transmission of pulmonary 

systolic murmur 390 

152 J. Point of maximum intensity and line of transmission of pulmonary 

diastolic murmur 391 

1525. Point of maximum intensity and line of transmission of pulmonary 

diastolic murmur 391 

153. Cook's modification of Eiva-Eocci's blood pressure instrument . . 397 

154. Stanton 's Sphygmomanometer 398 

155. The Erlanger sphygmomanometer with the Hirsclifelder attachments 

by means of Avhich simultaneous tracings can be obtained from 

the brachial, carotid, and venous pulses 399 

156. The Janeway sphygmomanometer which has been found a convenient 

and practicable instrument 400 

157. Eogers ' ' ' Tycos ' ' dial sphygmomanometer 402 

158. Illustrating the Faught blood pressure instrument. Detail of the 

dial in the ''Tycos" instrument 402 

159. Method of taking blood pressure with a patient in sitting position 404 

160. Method of taking blood pressure with patient lying down .... 404 

161. Observation by the auscultatory method and a mercury instrument 405 

162. Acute fibrinous pericarditis 408 

163. Pericardial adhesions 414 

164. Endocarditis, verrucose form 419 

165. Chronic endocarditis 422 

166. Fenestration of semilunar valves 425 

167. Normal ventricular systole. Mitral valve is closed ; aortic valve is 

open 426 

168. Normal ventricular diastole. Mitral valve is open. Aortic valve is 

closed 427 

169. Aortic regurgitation. Mitral and aortic valves are open during 

diastole 428 

170. Aortic stenosis. Mitral valve is closed during ventricular systole. 

Aortic orifice is stenotic 435 

171. Chronic endocarditis with coalescence of two aortic cusps .... 437 

172. Mitral regurgitation. Mitral and aortic valves open during ven- 

tricular systole 442 

173. Mitral stenosis. Ventricle during late diastole or presystole . . . 452 

174. Enormous hypertrophy of left ventricle due to prolonged increased 

peripheral resistance 471 

175. Aortic incompetence with hypertrophy and dilatation of left ven- 

tricle, the result of arteriosclerosis affecting the aortic valves . 476 

176. Eeptilian heart 479 

177. Anatomical landmarks of abdomen 487 

178. The abdominal surface with the rib margins and the iliac crests 

outlined . 488 

179. Another abdominal surface, Avith the ribs aiid crests outlined . . . 490 

180. The usual anatomic division of the abdomen into nine regions by two 

transverse lines and two vertical lines 491 

181. The abdominal surface divided into quadrants 493 

182. Another abdomen divided with the circle and short horizontal lines, 

and showing the names on the primary regions 494 

183. Establishment of collateral circulation in portal vein obstruction and 

mediastinal tumor 497 

184. Abdominal arteries in a case of double iliac thrombosis of typhoid 

origin 498 

185. A small umbilical hernia with a relaxed abdominal wall .... 499 

186. A large ventral hernia at the site of an operation scar 499 

187. Stenosis in the vicinity of the splenic flexure 500 

188. Stenosis of the lower ileum from peritoneal adhesion 502 



22 ILLUSTRATIONS 

PIG. ■* PAGE 

189. Normal intestinal peristalsis 503 

190. Median grooving of the abdominal wall where there is separation of 

the recti muscles 504 

191. Obesity. (Patient lying.) . 504 

192. Obesity. (Patient standing.) 505 

193. Obesity, mistaken for pregnancy by patient 506 

194. Contour of the abdomen in pregnancy with patient recumbent . . 506 

195. Tympanites, mistaken for pregnancy by the patient 507 

196. Extreme ascites 507 

197. Showing the area of dullness in moderate ascites, with the patient 

lying on her back 508 

198. Showing the reason for the disposition of the dull and resonant areas 

in a case of moderate ascites 508 

199. Ascites. Eepresenting the patient turned on one side 508 

200. Indicating the area of dullness in moderate ascites, with the patient 

standing 509 

201. Indicating the area of dullness in a case of moderate ascites, with 

the patient turned on the left side 510 

202. Abdominal enlargement due to ovarian cyst 510 

203. Palpation of the abdomen. First step 512 

204. Palpation. Depressing the wall with the fingers of one hand, in 

various situations 512 

205. Palpation with both hands , 512 

206. Deep palpation with both hands 512 

207. Testing the thickness of the abdominal wall 513 

208. Testing the thickness of the abdominal wall (second step) . . . 513 

209. Various areas of significant point-tenderness 514 

210. Trying for a fluid wave across the abdomen 515 

211. Differentiating a fat wave from a fluid wave 515 

212. Ordinary percussion, which is usually rather superficial 517 

213. Deep percussion 517 

214. Showing the lines for mensuration . 518 

215. The central upper abdomen 521 

216. Palpation of the epigastrium 525 

217 A. Traube's semilunar space 527 

217B. Traube's semilunar space 527 

218. Illustrating point of epigastric tenderness in gastric ulcer .... 528 

219. Illustrating dorsal pressure point in gastric ulcer 529 

224. Palpating for tenderness or a mass in the appendix region . . . 539 

stomach or pancreas 530 

221. The left upper abdomen 533 

222. Tlie right lower abdomen 536 

223. Indicating the point to seek for appendix tenderness ..... 539 

224. Palpating for tenderness or a mass in the appendix region . . . 539 

225. Palpating for the appendix itself, to determine whether or not there 

is any appreciable infiltration and thickening of it ... . 540 

226. Another method of palpating the appendix 540 

227. The left lower abdomen 541 

228. Palpation of the ascending colon 543 

229. Palpation of the descending colon . 544 

230. Eolation of pancreas to adjacent viscera ■ . . . 545 

231. The right upper abdomen 550 

232. Corset liver 552 

233. Indicating the site for tenderness or a mass due to disease of the 

gall bladder 557 

234. Palpation of liver 558 

235. Hepatic enlargement due to carcinoma of head of pancreas . . . 559 

236. Dorsal pressure point in cholelithiasis 560 

237. Palpating for general tenderness of the liver 561 

238. Showing the site for tenderness of the left lobe of the liver . . . 562 



ILLUSTRATIONS 23 

FIG. PAGE 

239. Indicating the region for dullness from enlarged liver 566 

240. Indicating the area in which to search for splenic tenderness or 

enlargement 573 

241. Palpation of the spleen 574 

242. Indicating the region for dullness from enlarged spleen 579 

243. Splenic enlargement in leukemia 580 

244. Surface markings of kidneys, ureters and abdominal vessels. An- 

terior view 584 

24:5A. Topographic anatomy of kidneys and ureters 585 

245J5. Topographic anatomy of kidney and ureters 585 

246. Palpation of kidney 588 

247. Indicating the region for kidney tenderness in front, on the right side 589 

248. The point for kidney tenderness laterally 590 

249. The point for kidney tenderness posteriorly 590 

250. The area for left kidney tenderness in front 591 

251. Method of palpating for a mass in the kidney region 592 

252. Points for kidney tenderness laterally 593 

253. Points for kidney tenderness in the back 594 

254. Indicating the site to search for tenderness of the right ureter . 597 

255. Palpating for tenderness or thickening about the right ureter . . 597 

256. Alopecia areata 601 

257. Alopecia areata 602 

258. Syphilitic alopecia 60S 

259. Face of acromegaly 606 

260. A case of congenital myxedema 606 

261. Face of myxedema 607 

262. Leprosy 607 

263. Facial hemiatrophy 608 

264. Saddle-nose 615 

265. Mucous patches ' 616 

266. Chancre of the lip of one month 's duration 616 

267. Prickle-celled carcinoma of the lower lip in a young man, Avhich arose 

after treating a clinically benign lesion with caustic pastes . . 617 

268. Double harelip and cleft palate 618 

269. Case of complete double cleft in which at birth a tooth hung from 

the lateral margin of the alveolar cleft by a thin pedicle of 

soft tissue 618 

270. Complete double cleft of the lip. This is here accompanied by a 

double cleft of the palate. The intermaxillary bone carries 

three incisors 619 

271. Noma, A piece has been removed from the left cheek for examina- 

tion 619 

272. Hutchinson's teeth 620 

273. Illustrating tuberculous lesions of the tongue 623 

274. ' ' Cobblestone tongue ' ' due to gummous deposits two years after 

infection 624 

275. Goiter 630 

276. Palpation of thyroid gland 630 

277. Palpation of submaxillary and submental glands 631 

278. Congenital hemangioma of neck 632 

279. Hodgkin's disease 633 

280. Branchial cyst 634 

281. Hypertrophy of the nails 637 

282. Symmetrical atrophy of nails 637 

283. Hebreden's nodes 639 

284. Pulmonary osteoarthropathy 639 

285. Arthritis deformans 640 

286. Morvan's disease 640 

287. Spade hand 642 

288. Claw hand 642 



24 ILLUSTRATIONS 

FIG. * PAGE 

289. Accoucheur's hand 643 

290. Wrist-drop 643 

291. Pellagra 645 

292. Pellagra in child less than 3 years old 646 

293. Lipoma of arm 648 

294. Gangrene of toes 650 

295. A case of rickets • 652 

296. A case of rickets 652 

297. Showing extreme case of bowlegs 653 

298. Varicose ulcer of leg 654 

299. Osteosarcoma of femur 655 

300. Little's disease 660 

301. Little's disease 660 

302. Percussion hammer 667 

303. Elicitation of Babinski's sign 669 

304. Elicitation of patellar tendon reflex 670 

305. Elicitation of ankle clonus . 671 

306. Facial paralysis 683 

307. Facial paralysis 683 

308. Chart 699 

309. Chart 701 



PHYSICAL DIAGNOSIS 



PART I. THE THORAX 

SECTION I 



CHAPTER I 
CLINICAL ANATOMY OF THE THORAX 

The bony thorax resembles in shape a truncated cone with an 
anteroposterior flattening, which causes the transverse diameter 
to exceed the anteroposterior diameter by one-fourth. AVhen the 
thorax is vicAved in the living subject, however, the upper portion, 
which corresponds to the apex of the cone which is formed by the 
bony thorax, exceeds in transverse diameter the lower portion of 
the thorax as a consequence of the investment of the thoracic cage 
by the bulky muscles of the shoulder girdle. The thoracic walls 
are formed by the rigid vertebral column posteriorly, and the ribs 
posteriorly, laterally, and anteriorly. The sternum enters into the 
formation of a large portion of the anterior wall ; and posteriorly 
the thorax is reinforced by the overlying scapulae, which cover the 
ribs upon either side of the vertebral column from the spinous 
processes of the second to the seventh dorsal vertebrae. 

The intercostal spaces are occupied by the intercostal muscles, 
which are further reinforced by the investing fascia and the par- 
ietal pleura. These spaces are traversed by the intercostal 
vessels and nerves, the latter sending out their lateral cutaneous 
branches in series at points situated midway between the spines 
of the thoracic vertebrae and the sternum. Similarly, the term- 
inal filaments of the intercostal nerves emerge at points in series 
near the lateral margins of the sternum. In the presence of inter- 
costal neuralgia the points of exit of these cutaneous nerves are 
not infrequently subject to pain upon pressure, constituting 
Valleix's points of tenderness. 



26 



PHYSICAL DIAGNOSIS 




Fig. 1. — Relations and surface markings of thoracic and abdominal viscera. 
(Anterior view.) 



CLINICAL ANATOMY OF THE THORAX 



27 



UPPLR LObL 



UPPER LOBE 




Fig -• — Relations and surface markings of thoracic and abdominal viscei 
(Posterior view.) 



28 PHYSICAL DIAGNOSIS 

The thoracic wall varies in thickness in different regions of 
the chest, and also with the degree of physical development of the 
individual. Clothed in all parts by the overlying musculature, it 
is further reinforced posteriorly by the interposition of the os- 
seous scapulae, and anteriorly by the mammary gland in the fe- 
male subject. In the axillary, infraaxillary, interscapular, and 
subscapular regions, on the other hand, the thoracic wall does not 
attain great thickness ; consequently in these regions physical signs 
arising within the thorax are more clearly transmitted to the 
examining ear. In the subject of excessive muscular development 
as well as in the presence of general obesity a thick chest wall is 
the rule, while in the poorly nourished individual with imperfect 
development of the muscular system, the walls of the thorax are 
unduly thin and the scapula are readily displaced from their nor- 
mal beds. The thoracic wall possesses less thickness in the fe- 
male subject than in the male, owing to the greater degree of 
muscular development in the latter class. In the child, again, 
the chest wall is very thin and resilient, and physical signs aris- 
ing Avithin the thorax are transmitted thence with a correspond- 
ing increase of intensity. 

The thoracic wall of the normal subject possesses an inherent 
elasticity, yielding readily to variations of pressure exerted from 
without or from within the cavity of the thorax. Consequently, 
characteristic deformity of the contour of the thorax readily re- 
sults from occupation or from disease as, for example, the funnel- 
breast deformity of the shoemaker or carpenter, the barrel-chest 
of hypertrophic emphysema, or the elongated, alar thorax of 
chronic phthisis. As a result of this great plasticity of the thor- 
racic parietes, careful inspection of the contour of the thorax 
assumes a very important role in physical diagnosis. 

The thoracic cavity, containing the great organs of respiration 
and circulation, is limited inferiorly by the diaphragm and supe- 
riorly by the dome of the parietal pleura, which is reinforced in 
this region by a thickening of the investing fascia, Sibson's fascia. 
The capacity of the thoracic cavity is not commensurate with the 
external dimensions of the thorax. Inferiorly the dome of the 
diaphragm ascends as high as the upper border of the fifth rib in 
the right midclavicular line, and to the lower border of the fifth 
rib in the corresponding line upon the opposite half of the thorax ; 
but, as if to compensate in some degree for this deficiency infe- 
riorly, the cavity ascends beneath the dome of the pleura into the 



CLINICAL ANATOMY OF THE THORAX 



29 



root of tlie neck to a height varying from one to one and one-half 
inches above the clavicle. 

The thoracic cavity is divided by reflections of the parietal pleura 
into three chambers; namely, a pleural cavity upon either side of 
the median line, intervening between which is a third cavity, the 
mediastinum. 

The pleural cavities, occupying the lateral regions of the thoracic 
cavity, extend upward into the base of the neck to the extent of 
one to one and one-half inches above the clavicle, and downward as 
low as the attachment of the diaphragm to the thoracic walls. The 
vertical diameter of each pleural cavity is diminished by the ascent 




Fig 3. — Relations of the lungs with the anterior thoracic wall. 



of the diaphragm during expiration, whereas the transverse and 
anteroposterior diameters of the cavity are increased by the excur- 
sion of the chest wall during inspiration. 

The pleural cavity is lined internally by a thin serous membrane, 
the pleura, which closely invests its walls, in which situation it is 
termed the parietal pleura. For purposes of description and ac- 
curate localization, several subdivisions of the parietal pleura are 
recognized according to the distribution of the membrane. The 
portion of the membrane which invests the anterior, lateral, and 
posterior walls of the cavity constitutes the costal pleura; the por- 
tion which clothes the superior surface of the diaphragm, forming 



30 PHYSICAL DIAGNOSIS 

the inferior limit of the pleural cavity, is designated the diaphragm- 
atic pleura; while the folds which are reflected from the anterior 
to the posterior thoracic walls, forming in this wise the lateral walls 
of the mediastinum, are termed the mediastinal pleura. The same 
membrane is reflected from the mediastinal wall on to the lung at 
its root, clothing the external surface of the lung completely and 
dipping into the fissures of the organ, forming the visceral pleura. 

In the normal subject the pleural membrane is moistened with 
a small amount of serous fluid, which permits the visceral and the 
parietal pleura to glide noiselessly over each other during the 
movements of the lung and the chest wall during respiration. In 
the presence of inflammation of the membrane, however, the pleural 
surface loses its smooth, glistening appearance, and becomes coated 
with a variable amount of fibrinous exudate, giving rise to a coarse 
or grating sound during the respiratory movements, which is rec- 
ognized by the clinician as the pleural friction sound. 

The mediastinum, the central portion of the thoracic cavity inter- 
vening between the pleural cavities, is limited anteriorly by the 
sternum and costal cartilages, and posteriorly by the bodies of 
the thoracic vertebra, while its lateral walls are formed by the re- 
flection of the parietal pleura from the anterior to the posterior 
wall of the thorax. This important portion of the thoracic cavity 
is arbitrarily divided into four subdivisions ; namely, the superior, 
posterior, anterior, and middle mediastina. 

The superior mediastinum is represented by the portion of the 
mediastinal space which is situated above the lower border of the 
manubrium sterni anteriorly and the lower border of the body of 
the fourth dorsal vertebra posteriorly. As in the case of the re- 
maining subdivisions of the mediastinum, its lateral walls are 
formed by the mediastinal reflections of the parietal pleura. This 
space contains the intrathoracic portion of the trachea together 
with the tracheal glands, the esophagus, and the superior portion 
of the thoracic duct. The superior mediastinum also lodges the 
arch of the aorta, with the initial portions of the three great arte- 
rial trunks which spring from its convexity; and here also are 
found the innominate veins, uniting to form by their confluence 
the superior vena cava. 

The posterior mediastinum represents the downward continua- 
tion of the posterior portion of the superior mediastinum, whence 
it extends as low as the upper surface of the diaphragm, which 
separates it from the abdominal cavity. Bounded laterally by the 
mediastinal pleura and posteriorly by the bodies of the dorsal 



CLINICAL ANATOMY OF THE THORAX 31 

vertebrae, the posterior mediastinum is in direct relation anteriorl}^ 
with the pericardium and heart. The posterior mediastinum 
contains the descending thoracic aorta, the esophagus in close rela- 
tion with the pneumogastric nerves, a portion of the thoracic duct, 
and likewise a portion of the azj^gos veins. The space also lodges a 
chain of lymphatic glands, which are apt to become enlarged in 
the presence of intrathoracic malignant disease. 

The middle mediastinum is situated immediately below the ante- 
rior portion of the superior mediastinum, and it is interposed be- 
tween the anterior mediastinum ventrally and the posterior medi- 
astinum dorsally, while its inferior limit or floor is formed by the 
central tendon of the diaphragm. That this is the most important 
subdivision of the mediastinum to the student of physical diagnosis 
is evident, when it is recalled that this limited space contains the 
pericardium and heart, the ascending aorta, the pulmonary artery 
with its two primary branches, the bifurcation of the trachea, the 
primary bronchi with their related bronchial glands, as well as the 
lower portion of the superior vena cava and its junction with the 
azygos veins. 

The anterior mediastinum is a narrow space situated immediately 
behind the sternum. It is limited posteriorly by the pericardium 
and laterally by reflections of the parietal pleura from the anterior 
thoracic wall. The space is of little diagnostic interest, save that 
it lodges a few lymphatic glands, which may become enlarged or 
become the seat of malignant disease. 

As the mediastinum is traversed by such a variety of important 
structures, it is evident that physical signs arising from medias- 
tinal disease are apt in many instances to manifest themselves in 
the form of pressure symptoms. Pressure generated within this 
space, being exerted upon the large blood vessels, upon the large 
lymphatic tract represented by the thoracic duct, upon the esopha- 
gus or upon the air passages, will in each instance produce physical 
signs of definite localizing value. Moreover, as a result of the close 
contiguity of so many vital anatomic structures within a restricted 
space, inflammation of a single structure is apt to involve adjacent 
organs, resulting in the formation of inflammatory adhesions or 
frank abscess formation. 

The thoracic viscera comprise the air passages, represented by 
the larynx, trachea, and bronchi ; the essential organs of respira- 
tion, the lungs ; and the circulatory organs, represented by the 
pericardium and heart with the great vessels arising from its base. 

The larynx must be considered in conjunction with the trachea 



32 



PHYSICAL DIAGNOSIS 



and bronchi, as it constitutes an essential portion of the air pas- 
sages. This important structure occupies a position in the neck 
between the base of the tongue and the trachea, and opposite the 
bodies of the fourth, fifth, and sixth cervical vertebra. In the 
ventral portion of the neck the larynx forms a visible prominence, 
the pomum Adami, lateral displacement of which is often signifi- 
cant of intrathoracic disease. Similarly, abnormalities in the res- 




Fig. 4. — The bronchial tree. The walls of the bronchi contain cartilage in incomplete 
rjngs or plates distributed about their entire circumference. The cartilage and the elastic 
tissue make the tubes firm-walled; only the fine branches of one mm. or less in diameter 
have no cartilage, and are consequently collapsible. (From Brown.) 



piratory movements of the larynx are often the deciding factor in 
the determination of the cause of dyspnea ; while a palpable tug of 
the larynx is not infrequently symptomatic of aortic aneurysm. 

The cavity of the larynx contains the true and false vocal cords, 
intervening between which is the ventricle. The slight interval 



CLINICAL ANATOMY OF THE THORAX 33 

between the true cords constitutes the chink of the glottis or rima 
glottidis, variations in the dimensions of which influence the in- 
tensity of physical signs which are dependent upon the spoken 
voice for their production. 

The mucous lining of the upper portion of the larynx is quite 
thick and vascular, and, in the presence of inflammatory affections 
of neighboring structures, is apt to swell from effusion into the 
submucous coat with the production of edema of the glottis, and 
stridulous respiration. The close adhesion of the mucous mem- 
brane to the true vocal cords prevents the effusion from extending 
below these structures. 

The trachea, the second portion of the respiratory passage, has 
the form of a cylindrical tube with slight flattening of the posterior 
wall. Extending from its junction with the cricoid cartilage of 
the larynx opposite the sixth cervical vertebra to its bifurcation 
to form two primary bronchi at the level of the fourth dorsal verte- 
bra, in the neck it is covered by the flat infrahyoid muscles, the 
isthmus of the thyroid gland, and the integument; while within 
the thorax it is covered by the thymus gland in the child, and by 
the remnant of this gland and by the arch of the aorta in the adult 
subject. The trachea of the adult is from four to four and one-half 
inches in length. 

The trachea is a composite structure formed by from sixteen to 
twenty incomplete cartilaginous rings, invested externally by a 
fibrous membrane and lined internally by mucous membrane con- 
taining numerous mucous glands, whose secretion prevents exces- 
sive dryness of the sensitive mucous lining of the tube. In the 
presence of tracheobronchial irritation and inflammation, these 
glands pour out an excessive, tenaceous secretion. 

The free ends of the cartilaginous rings, of which the trachea 
is largely composed, are directed posteriorly, in which situation 
the deficiency in the wall of the tube is closed by transverse bun- 
dles of involuntary muscle, constituting the trachealis muscle 
of Todd and Bowman. The transverse bands of this muscle, the 
contraction of which serve to diminish the lumen of the trachea, 
are invested externally by bands of nonstriated muscular fibers 
which extend the entire length of the tube. 

The hronchi pass obliquely downward and outward from their 
origin at the tracheal bifurcation to enter the roots of their re- 
spective lungs. The left bronchus, which is approximately two 
inches in length, enters the root of the left lung at a point opposite 
the sixth thoracic vertebra. In its course the left bronchus crosses 



34 PHYSICAL DIAGNOSIS 

the esophagus, thoracic duct, and descending aorta. The left pul- 
monary artery occupies a position at first superior to, and in its 
course finally comes to occupy a position posterior to, the bronchus. 
The arch of the aorta crosses above the left bronchus ; and, in the 
presence of aneurysm of this portion of the vessel, is apt to pro- 
duce a downward displacement of the bronchus which is responsible 
for the systolic trachael tug which not infrequently characterizes 
this condition. As the left bronchus is smaller and more deeply 
situated in the thoracic cavity than is the corresponding bronchus 
of the right side, and as it forms a more acute angle with the 
trachea than does the right bronchus, physical signs arising within 
it are not conducted to the surface of the thorax with the same de- 
gree of intensity as are similar sounds generated within the right 
bronchus. 

The right hronchus, approximately one inch in length, passes 
almost vertically downward to enter the root of the right lung 
opposite the fifth thoracic vertebra. The vena azygos major courses 
upward behind the right bronchus ; and, arching over the tube, 
joins the superior vena cava, which is in relation with the bronchus 
anteriorly. The right pulmonary artery occupies initially a posi- 
tion below the corresponding bronchus, and in its further course 
occupies a position anterior to it. 

The tracheohronchial lymph nodes are collected into four prin- 
cipal groups along the course of the trachea and bronchi. A group 
of these glands occupies the angle between the trachea and right 
bronchus upon the right side, while a similar group occupies the 
angle between the trachea and the left bronchus upon the opposite 
side. A large group of glands is clustered in the angle which is 
formed by the tracheal bifurcation. Finally, the interbronchial 
nodes occupy the angles of bifurcation of the larger bronchi 
throughout the pulmonary parenchyma. With advancing age these 
glands become deeply pigmented as a result of the deposition of 
carbonaceous material from the pulmonary alveoli and finer bron- 
chioles; and in the presence of malignant disease they become 
chronically enlarged with the production of pressure signs. 

The lungs, suspended by their respective roots, and covered upon 
their surfaces by the visceral pleura, hang free within the pleural 
cavities. The lungs during life entirely fill the pleural sacs, so 
that the latter represent only potential cavitiep.. Each lung pos- 
sesses an apex, which ascends one to one and one half inches above 
%he clavicle beneath the dome of the pleura; a base, which rests 



CLINICAL ANATOMY OF THE THORAX 35 

upon the convex superior surface of the diaphragm; a convex or 
costal surface, which is in contact with the anterior lateral, and 
posterior thoracic walls; and an irregular internal surface, which 
bears the imprint of a number of structures contained within the 
mediastinum with which it is in relation. 

The left lung is divided into two lobes by a deep fissure, which 
extends well in toward the root of the lung, and which is lined by 
a reduplication of the visceral pleura. In inflammation of the 
pleura the portion of the membrane which dips into the fissure 
may be the only portion of the membrane involved, with the conse- 
quent production of a condition of interlobar pleurisy very difficult 
of detection by physical means. 

The upper lobe of the left lung comprises a large portion of the 
external surface and the entire anterior border of the lung, while the 
lower lobe comprises the entire base and the greater portion of the 
posterior border of the lung. This is an anatomic fact of consider- 
able importance, as during a physical examination it is frequently 
desirable to ascertain whether a morbid process having its inception 
in the apex or upper lobe of the lung has progressed to the lower 
lobe. 

The right lung is divided into three lobes by two fissures. The 
upper lobe comprises the apex, a little more than half of the exter- 
nal surface, and the portion of the anterior border of the lung above 
the level of the fourth costal cartilage. The lower lobe comprises 
the entire base of the lung, but only a limited portion of the ex- 
ternal surface. The middle lobe of the right lung is a wedge- 
shaped portion interposed between the upper and lower lobes, com- 
prising the anterior portion of the external surface of the lung 
below the level of the fourth costal cartilage. 

The external surface of each lung is convex ; whereas the internal 
surface, which is in contact with the mediastinum, presents de- 
pressions corresponding to the mediastinal structures with which 
it is in relation. 

The internal surface of each lung is marked by a rather deep 
depression, which receives the pericardium and heart. This de- 
pression is much more distinctly marked upon the left lung, owing 
to the projection of the heart to the left side of the median line 
of the thoracic cavity. Situated immediately above and behind the 
cardiac depression, each lung presents the hilus or pulmonary root, 
for the entrance of the primarj^ bronchus with the accompanying 
vessels, lymphatics, and nerves of the lung; while extending down- 



36 PHYSICAL DIAGNOSIS 

ward from the hilus is a fold of the reflected *pleura, the ligamentum 
latum pulmonis. 

In addition to these impressions, the internal surface of the 
left lung is traversed by a fairly deep groove, which curves above 
the left bronchus and descends behind this tube, and which lodges 
the aorta. A second groove, which lodges the subclavian artery, 
passes upward from the aortic groove at the point where the latter 
arches over the pulmonary root. 

The internal surface of the right lung is traversed by a groove 
which, arching over the right bronchus, lodges the vena azygos 
major. Extending upward from the fore part of this groove is a 
second groove which is traversed by the superior vena cava. 

The lungs present certain individual differences which have an 
influence upon physical signs emanating from the two sides of the 
thorax. The apex of the right lung mounts to a greater height in 
the root of the neck beneath the dome of the pleura than does that 
of the left lung. Similarly, the base of the right lung occupies a 
higher level than does the base of the left lung. But, in addition 
to its slightly higher position with reference to the opposite lung, 
the right lung has a greater transverse diameter than its fellow of 
the opposite side. Moreover, the anterior border of the right lung 
is approximately vertical, approaching the median line ; whereas 
the corresponding border of the left lung falls away from the 
median line in an oblique direction, exposing a portion of the 
right ventricle and pericardium in the interval which is created 
in this manner. 

The extent to which the anterior borders of the lungs approach 
each other varies with the depth of inspiration and the integrity 
of the pulmonary parenchyma, as well as with the state of the 
mediastinal structures. In the absence of mediastinal disease, uj^on 
forced inspiration the anterior pulmonary borders come forward 
and cover the base of the heart and the great vessels arising there- 
from and enveloped by the pericardium. At the completion of 
inspiration the anterior borders of the lungs are in contact from 
the lower border of the manubrium sterni to a point corresponding 
to the level of the fourth costal cartilage. At this stage of the 
respiratory cycle the anterior border of the right lung is vertical 
and parallel with the median line of the thorax, while the obliquely 
directed anterior border of the left lung covers all of the peri- 
cardium and heart save a limited portion corresponding to the 
lower third of the right ventricle. During tranquil respiration 
the anterior borders of the lungs do not come into contact at any 



CLINICAL ANATOMY OF THE THORAX 37 

point. Owing to the projection of the heart toward the left of the 
median line, the anterior border of the right Inng is the more mobile 
of the two, and during tranquil inspiration approaches nearly to 
the median line behind the sternum. 

Various factors may, however, modify the excursions of the an- 
terior pulmonary borders. In the presence of excessive cardiac 
hypertrophy or extensive pericardial effusion the borders do not 
meet over any portion of the pericardium. The same condition 
obtains in the absence of cardiac or pericardial disease when the 
heart is pushed forward by disease in the posterior mediastinum. 
Moreover, the excursion of the pulmonary borders is restricted 
by the formation of adhesions between visceral and parietal pleura, 
or by cirrhotic changes in the pulmonary parenchyma. 

As the anterior border of the right lung enjoys a greater freedom 
of movement than does the corresponding border of its fellow, so 
also the lower border of the right lung expands more freely than 
does that of the left lung. The apex of the left lung, on the con- 
trary, expands more freely than does that of the right lung. Dur- 
ing both tranquil and forced respiration the posterior portions of 
the lungs remain quietly in relation with the walls of the pleural 
cavities, while the apices, anterior borders, and bases expand and 
recede with inspiration and expiration. The excursion in any of 
these directions is apt to become deficient as the result of traction 
from adhesions or retrogressive changes in the lung. 

The internal structure of the lung is very intimately related 
to many symptoms and signs which are manifested during disease 
of these organs. The primary bronchus, which enters the lung at 
the hilus, divides dichotomously until, after repeated divisions, 
very fine branches termed bronchioles are formed. The bronchioles 
have no communicating branches with the result that when an ob- 
struction of one branch develops, air is withheld from the vesicles 
in which it terminates, and a condition of localized atelectasis in- 
evitably results. 

In the bronchiole there is a gradual transition of the stratified 
columnar epithelium of the bronchus into simple columnar epithe- 
lium, which in turn, near the distal end of the terminal bronchiole, 
gives place to small groups or islands of flat epithelial cells, res- 
piratory epithelium. The epithelial lining of the terminal bronchi- 
ole is supported by a thin basement membrane, beneath which is a 
tunic containing numerous elastic fibers and circularly disposed 
bands of involuntary muscular fibers, spasm of which possibly 
plays a part in the production of the paroxysm of bronchial asthma. 



o8 PHYSICAL DIAGNOSIS 

■ « 

Each terminal bronchiole terminates in an irregularly pyramidal 
chamber, the infimdihuliim, which constitutes the ''blood- vascular 
unit" of the lung. The walls of the infundibula comprise a series 
of minute, blind pouches, the alveoli, which are lined with a single 
layer of flat respiratory epithelium supported by a delicate base- 
ment membrane containing numerous elastic fibers. These elastic 
fibers render the infundibular walls very resilient and play an im- 
portant part in the expansion and recession ' of the lung during 
respiration. 

Each infundibulum is invested by a dense capillary plexus de- 




Fig. 5. — Pulmonary capillaries. The walls of the alveoli are thickly studded with 
capillaries; any marked alteration of alveolar air tension will therefore have a profound 
effect upon the circulation. (Brown, after Bohm, Davidoft, and Huber.) 

rived from branches of the pulmonary artery, which accompany 
the bronchi and bronchioles in their ramifications throughout the 
lung. The capillary plexus surrounding each infundibulum is dis- 
posed in a single layer, and there is no communication with the 
vessels of adjacent infundibula. The blood content of these capil- 
laries is very intimately exposed to the air in the infundibula, as 
they are separated only by three very thin membranes; namely, 
the endothelium of the capillary wall, the delicate basement mem- 



CLINICAL ANATOMY OF THE THORAX 39 

brane of the infundibulum, and the single layer of infundibular 
epithelium. In hypertrophic emphysema, when the interalveolar 
septa are destroyed, as the capillary plexus of each infundibulum 
is distinct and has no communication with those of adjacent in- 
fundibula, the amount of blood exposed to the air in the large 
cavities which are formed by coalescence of several infundibula is 
considerably reduced, leading to dyspnea upon slight exertion in 
this class of patients. 

The lymphatics of the lungs drain into the tracheo-bronchial 
lymph nodes and the mediastinal glands, with the result that these 
glands are early involved in tuberculous infection of the lungs, or 
when the lung is the seat of malignant disease. Similarly, these 
glands serve as filters for the irritant dusts which are conveyed to 
them by phagocytes from the finer bronchioles and infundibula in 
pneumonokoniosis. 

Topographical Anatomy of the Thorax 

The Pleura, — The surface markings of the pleura correspond to 
a line drawn from either sternoclavicular articulation downward 
and inward to the transverse ridge which marks the junction of the 
manubrium and gladiolus of the sternum. Thence the anterior 
borders of the reflections of the pleural membranes pass vertically 
downward slightly to the right of the median line to the level of 
the fifth intercostal space. At this point upon the surface of the 
thorax the two membranes separate, and in their further course 
diverge the one from the other. 

The right pleura continues vertically downward almost to the 
junction of the gladiolus and the ensiform cartilage, w^hence it 
pursues an oblique course, passing outward, downward, and back- 
ward toward the vertebral column. In its course the lower border 
of the pleura cresses the seventh rib in the midclavicular line, the 
ninth rib in the midaxillary line, and the eleventh rib in the scapu- 
lar line. 

At the level of the fifth intercostal space the left pleura pursues 
a course toward the left and then downward to gain the posterior 
surface of the sixth costal cartilage in the left parasternal line. 
The membrane crosses the sixth costal cartilage vertically and from 
its lower border is reflected downward, outward, and backward 
toward the vertebral column, occupying a slightly lower level than 
does the lower border of the right pleura. In the interval which 
remains between the left sternal border and the left pleural mem- 



40 



PHYSICAL DIAGNOSIS 



brane in the fifth intercostal space, an interval which corresponds 
accurately with the incisura cardiaca of the anterior border of the 
left lung, a limited portion of the right ventricle is brought into 
direct relation with the anterior thoracic wall. 

The superior limit of the supraclavicular portion of the pleura, 
representing the dome of the pleural cavity, is indicated by a line 
drawn obliquely upward and outward from the sternoclavicular 
articulation upon either side, crossing the lower portion of the root 




lOWEK MARGIN 
OF LUIMG-- 



LOWER MARGIN 
OF PlEURA- 



OWtR MARGIW 
Of LUNG 



-LOWER MARGIN 
CF PlEDRA 



Fig 6. — Illustrating the normal borders of the lungs and the location of the interlobular 
septa. Anterior view. (Pottenger, after Corning.) 



of the neck so as to curve upward and descend to the spine of the 
seventh cervical vertebra. The maximum height of the curve, 
which corresponds to the apex or dome of the pleural cavity, is one 
to one and one-half inches above the clavicle. 

Upon the posterior surface of the thorax the course of the pleural 
reflection is represented by a vertical line drawn along either side 
of the vertebral column from the level of the seventh cervical 



CLINICAL ANATOMY OF THE THORAX 



41 



vertebra to the articulation of the eleventh rib with the vertebral 
column, whence the line is continued downward and outward in a 
gentle curve to meet the line of reflection of the anterior portion 
of the membrane. 

The Lungs. — The borders of the lungs correspond accurately 
with the line of reflection of the pleura, save that inferiorly the 
lower borders of the lungs fall short of the pleura by one inter- 




LOWER nARQlh 

or UJHQ — 



LOWER riARQ in 
Of PLEURA — 



Fig. 7. — Illustrating normal borders of the lungs and interlobular septa. 
(Pottenger, after Corning.; 



Posterior view. 



costal space, being found at the level of the sixth rib in the mid- 
clavicular line, the eighth rib in the midaxillary line, and the tenth 
rib in the scapular line. The interval between the lower border 
of the lung and the inferior limit of the pleural reflection upon 
either side, representing one intercostal space upon the surface of 
the thorax, is the complementary sinus, into which the lower border 
of the lung descends during forced inspiration. These surface 



42 



PHYSICAL DIAGNOSIS 



markings should be borne in mind when determining the total ex- 
pansion of the lungs by percussion. 

Fissures and Lobes of the Lungs. — The position of the great 
fissure, which is common to both lungs and which intervenes be- 
tween the upper and lower lobes, is represented by a line drawn 
upon the surface of the thorax from the spinous process of the 
third thoracic vertebra obliquely downward and forward to the 
lower border of the sixth rib in the midclavicular line. The shorter 
fissure, intervening between the upper and middle lobes of the right 
lung is represented by a line drawn upon the surface of the thorax 




Fig. 8. — Illustrating the normal borders of the lungs and the location of the interlobular 
septa. Lateral view. A, right; B, left. (Pottenger, after Corning.) 

from the apex of the axilla almost horizontally forward to meet 
the sternum at the level of the fourth right costal cartilage. 

Trachea and Bronchi. — The course of the trachea corresponds 
to a broad line passing vertically downward from the upper margin 
of the manubrium sterni to the level of the upper border of the 
second rib in the median line of the thorax. At this point upon the 
surface of the thorax the trachea divides to form the two primary 
bronchi, which diverge from each other in a downward and out- 
ward direction, the right bronchus inclining more directly down- 
ward than does the left. 



CLINICAL ANATOMY OF THE THORAX 



43 




Fig. 9. — Showing the position of the bifurcation of the trachea and the peri-tracheal 
anc] peri-bronchial glands projected upon the anterior surface of the chest in a young 
adult. (Pottenger, after Gerhartz.) 




Fig. 10. — Showing the position of the bifurcation of the trachea with the peri-tracheal 
and peri-bronchial glands projected upon the posterior surface of the chest in a yoimg 
adult. (Pottenger, after Piersol.) 



44 PHYSICAL DIAGNOSIS 

Anatomic Landmarks of the Thorax 

The thorax presents a number of anatomic structures which are 
visible or palpable, and which may be utilized as landmarks in the 
localization and description of morbid conditions arising within 
the thoracic cavity. 

At the superior border of the manubrium sterni there is normally 
a visible depression of moderate depth, occupying the interval be- 
tween the sternal attachments of the sternomastoid muscles, the 
episternal or siipr asternal notch, which is occasionally the site of 
abnormal pulsations. At the completion of expiration the superior 
border of the manubrium, which limits the episternal notch infe- 
riorly, occupies a position on a level with the disk between the 
second and third thoracic vertebrse. The interval between the 
vertebral column and the notch, representing the inlet of the 
thorax, measures approximately two inches in the normal subject. 

At the inferior extremity of the ensiform cartilage there is a 
second visible depression, the scrohiculus cordis, or pit of the 
stomach, which corresponds to the level of the midpoint of the body 
of the ninth thoracic vertebra. 

The sternum occupies the median line of the anterior surface of 
the thorax, surmounted by the episternal notch, and with the scro- 
hiculus cordis at its lower extremity. Of variable prominence in 
different subjects, and readily palpable throughout its entire extent, 
the sternum is approximately six inches in length in the normal 
adult. 

The angulus Luclovici, or angle of Louis, is a transverse ridge 
upon the sternum, which marks the junction of the manubrium and 
the gladiolus. It is usually visible upon the surface of the thorax 
and is always palpable. This ridge corresponds to the level of the 
junction of the second costal cartilage with the sternum, and it is 
frequently utilized as a starting point in counting the ribs and 
intercostal spaces. 

The clavicle, at all times a conspicuous landmark upon the ante- 
rior chest wall, in apical lesions of the lungs becomes very promi- 
nent, contrasting markedly with the supraclavicular fossa above 
it and with the infraclavicular fossa situated immediately below 
the bone. 

Upon either side of the thorax there are twelve rihs and eleven 
intercostal spaces. The first rib, situated rather deeply beneath 
the clavicle, is palpated with difficulty; but the remaining ribs 
are readily palpable and commonly visible in the form of moderate 
protrusions in the lower axillary and infraaxillary regions. Each 



CLINICAL ANATOMY OF THE THORAX 45 

intercostal space is named in accordance with the number of the rib 
immediately above it ; hence the first intercostal space occupies the 
interval between the first and second ribs. 

In counting the ribs one of several methods may be employed. 
In counting the ribs upon the anterior surface of the thorax it is 
convenient to commence the enumeration at the angle of Louis, 
which corresponds accurately to the second chondrosternal articu- 
lation. In counting the ribs upon the posterior surface of the 
thorax the inferior angle of the scapula may be utilized as a point 
of departure, as the tip of this bone overlies the seventh rib when 
the thorax is in repose. In the enumeration of the ribs upon the 
lateral aspect of the thorax the highest digitation of the serratus 
magnus muscle becomes the normal landmark, as this portion of the 
muscle overlies the sixth rib. The muscle may be rendered tense by 
abduction of the arm to a horizontal position. Certain clinicians 
prefer to proceed from below in counting the ribs, beginning with 
the extremity of the twelfth rib, which is palpable in the majority 
of subjects. 

The mammary gland in the male subject is a rudimentary struc- 
ture. In the female subject, however, it is well developed, and 
extends from the third to the seventh intercostal space in the mid- 
clavicular line. In the male subject the nipple is a reliable guide 
to the fourth intercostal space ; but in the female, owing to the 
pendulous condition of the breast, it is an unreliable landmark. 

The scapula overlies the dorsal aspect of the bony thorax, ex- 
tending along the vertebral column from the second to the seventh 
rib. Always readily palpable, the bone stands out prominently in 
the form of the '^ winged scapula" of the alar thorax of chronic 
phthisis. 

The vertebral column, or spine, in persons of excessive muscular 
development is represented by a linear, median furrow, and the 
spinous processes are palpated with difficulty. But in thin subjects 
and in children many of the spinous processes are visible with the 
patient in the erect posture ; and upon bending the trunk forward 
they are readily palpated and counted. The spinous process of the 
seventh cervical vertebra is always a conspicuous landmark, and it 
may be employed as a point of departure in the enumeration of the 
vertebra. Also the inferior angle of the scapula, which corresponds 
to the level of the spinous process of the seventh thoracic vertebra, 
may be utilized as a starting point in the enumeration. Lateral 
curvature of the vertebral column (scoliosis) or abnormal degrees 
of anteroposterior curvature (lordosis) may be encountered in con- 



46 PHYSICAL DIAGNOSIS 

nection with the thoracic deformities of rictets, hypertrophic em- 
physema, and in other forms of pulmonary disease. 

Topographical Lines and Regions 

For purposes of clinical description and for convenience in local- 
izing lesions arising within the thorax, a number of regions may be 
outlined upon the surface of the thorax by means of arbitrary 
vertical and horizontal lines. It is of the first importance that the 
student should become thoroughly familiar with the relations of the 
thoracic viscera to these several regions. 

Vertical Lines. — The fnidsternal line is a verticle line erected 
upon the anterior aspect of the thorax, traversing the midportion 
of the sternum from the midpoint of the superior border of the 
manubrium sterni to the tip of the ensiform cartilage. 

The sternal line conforms to the lateral border of the sternum 
from the sternoclavicular articulation to the junction of the gladio- 
lus with the ensiform cartilage, whence it is continued in a direction 
downward and outward along the course of the lower border of the 
costal arch to meet the anterior axillary line. 

The midclavicular line is a verticle line dropped upon the ante- 
rior thoracic surface from the midpoint of the clavicle. It fre- 
quently, though not invariably, passes through the nipple and 
hence is frequently termed the nipple line, or the mammary line. 

The parasternal line is a vertical line occupying a position upon 
the anterior aspect of the thorax midway between the sternal and 
the midclavicular lines. 

The anterior axillary line is a vertical line dropped along the 
lateral thoracic wall from the anterior fold of the axilla. 

The midaxillary line is a vertical line which passes down the 
lateral wall of the thorax from the apex of the axilla. 

The posterior axillary line is a line which is dropped along the 
lateral thoracic wall from the posterior fold of the axilla. 

The scapular line is a vertical line drawn upon the posterior 
surface of the thorax in such fashion as to pass through the tip of 
the inferior angle of the scapula. 

The midspinal line is a vertical line which conforms to the series 
of spinous processes of the vertebrae. 

Horizontal Lines. — The cricoclavicidar line is drawn from the 
prominence of the cricoid cartilage outward and with a slight in- 
clination downward to meet the prominence caused by the outer 
extremitv of the clavicle. 



CLINICAL ANATOMY OF THE THORAX 



47 



The clavicular line is a horizontal line passing outward from the 
sternoclavicular articulation, conforming to the course of the 
clavicle. 

The third costal line is drawn horizontally outward from the 
sternal line at the level of the third costal cartilage to meet the 
anterior axillary line. 

The sixth costal line is a horizontal line commencing at the 
sternal line at the level of the sixth chondrosternal articulation, 
which, after crossing the anterior axillary and midaxillary lines, 
terminates at the posterior axillary line. 

The scapular spinal line is a horizontal line projected outward 




Fig. 11. — Topographic regions of the thorax. (Anterior view.) 

upon the posterior thoracic wall from the scapular line, and con- 
forming to the course of the spine of the scapula. 

The infrascapular line is a line drawn horizontally across the 
posterior surface of the thorax at the level of the inferior angles 
of the scapula. 

The twelfth dorsal line is drawn from the point overlying the 
spinous process of the last thoracic vertebra, passing downward and 
outward to meet the posterior axillary line. 

Regions of the Thorax.- — Through the medium of these various 
vertical and horizontal lines, a number of regions are mapped out 
upon the surface of the thorax. 



48 



PHYSICAL DIAGNOSIS 



The sternal region overlies th-e sternum and is bounded above by 
the episternal notch, below by the scrobiculus cordis, and laterally 
by the sternal lines. The upper portion of the sternal region, over- 
lying the manubrium sterni, contains the anterior borders of the 
lungs, together with the bifurcation of the trachea, and the arch of 
the aorta. This region also is traversed by the left innominate vein 
and the beginning of the superior vena cava. The lower portion of 
the sternal region, corresponding to the distribution of the gladio- 




Fig. 12. — Topographic regions of the thorax. (Posterior view.) 



lus, overlies the greater portion of the right ventricle together with 
the edge of the left ventricle, as well as a portion of the anterior 
borders of both lungs. Within this region also are found the 
origin of the pulmonary artery and the ascending aorta, and the 
space also includes the right auricle. This region overlies the at- 
tachment of the pericardium to the diaphragm, and also a limited 
portion of the left lobe of the liver. 

The supraclavicular region lies in the base of the neck, above 
the clavicle, bounded above by the cricoclavicular line and infe- 
riorly by the clavicular line. These regions, upon either side, con- 



CLINICAL ANATOMY OF THE THORAX 49 

tain the apices of the lungs, the common carotid and subclavian 
arteries, together with the subclavian and jugular veins. 

The infraclavicular region is situated immediately below the 
clavicle. It is bounded above by the clavicular line, below by the 
third costal line, internally by the sternal line, and externally by 
the anterior axillary line. The anatomic structures lying within 
the limits of the infraclavicular regions differ upon the two sides 
of the thorax. The left infraclavicular region overlies the upper 
lobe of the left lung; and, adjacent to the left sternal border, a 
portion of the left auricle and the left pulmonary artery, as well as 
a portion of the left bronchus. The right infraclavicular region 
contains within its limits the greater portion of the upper lobe of 
the right lung, with the termination of the right bronchus, and the 
right pulmonary artery. 

The mammary region lies immediately below the infraclavicular 
region, upon either side of the thorax, limited above by the third 
costal line, below by the sixth costal line, internally by the sternal 
line, and externally by the anterior axillary line. 

As in the case of the infraclavicular regions, so also in the mam- 
mary regions the structures which are contained within the limits 
of these regions vary widely upon the two sides of the thorax. The 
left mammary region contains a portion of both lobes of the left 
lung, as well as the greater portion of the heart and pericardium, 
the latter partially overlapped by the anterior border of the left 
lung. The right mammary region contains a portion of the right 
auricle and right ventricle, partially overlapped by the anterior 
border of the right lung, which occupies the major portion of this 
region. The right lobe of the liver, clothed by the diaphragm, as- 
cends in this region as high as the upper border of the fifth rib in 
the midclavicular line. 

The hypochondriac region lies immediately below the mammary 
region, upon either side of the thorax, between the sixth costal line, 
the anterior axillary line, and the downward and outward continu- 
ation of the sternal line along the line of the costal arch. The con- 
tents of the regions vary upon the two sides of the thorax. 

The left hypochondriac region contains the complementary sinus 
into which the lower border of the left lung descends during inspi- 
ration, the cardiac end of the stomach, the diaphragm, and the tip 
of the left lobe of the liver, The right hypochondriac region, in ad- 
dition to the lower border of the right lung, contains within its 
limits the right lobe of the liver, covered by the diaphragm. 

The axillary region occupies the superior portion of the lateral 



50 PHYSICAL DIAGNOSIS 

aspect of the thorax, limited superiorly by tlTe apex of the axilla, in- 
feriorly by the sixth costal line, anteriorly by the anterior axillary 
line, and posteriorly by the posterior axillary line. This region 
upon both sides of the thorax contains only pulmonary tissue, hence 
upon percussion it yields a frankly resonant note. 

The infraaxiUary region, lying immediately below the axillary 
region upon the lateral aspect of the thorax, is bounded by the ante- 
rior and posterior axillary lines, the sixth costal line, and the down- 
ward prolongation of the sternal line along the costal arch. 

The left infraaxiUary region contains the lower portion of the 
left lung, the lower border of which reaches the eighth rib in the 
midaxillary line. The space also contains the diaphragm, and be- 
low this muscle a portion of the stomach and the spleen. The right 
infraaxiUary region contains, in addition to the right lung and the 
diaphragm, a portion of the right lobe of the liver. 

The suprascapular region overlies the supraspinous fossa of the 
scapula upon the posterior wall of the thorax, and is limited below 
by the scapular spinal line. The only structure within this region 
is the pulmonary apex upon either side of the thorax. 

The scapular region, overlying the infraspinous fossa of the 
scapula, is limited superiorly by the scapular spinal line and in- 
feriorly by the infrascapular line. This region upon either side 
of the thorax contains the posterior voluminous portions of the 
lungs, including a portion of both upper and lower lobes. 

The infrascapular region upon either side of the thorax is limited 
superiorly by the infrascapular line, inferiorly by the twelfth dor- 
sal line, and externally by the posterior axillary line. The an- 
atomic structures within the limits of this region vary upon the 
two sides of the thorax. 

The left infrascapular region overlies the lower lobe of the left 
lung, its inferior margin reaching the tenth rib in the scapular 
line. This region also contains the thoracic aorta in the lower por- 
tion of its course, and below the diaphragm a portion of the left 
kidney and of the spleen. The right infrascapular region contains, 
in addition to the lower lobe of the right lung, a portion of the 
right lobe of the liver, and of the right kidney. 

The interscapular region occupies the interval upon either side 
of the thorax between the scapular line and the midspinal line, 
limited inferiorly by the infrascapular line. The structures con- 
tained in the two regions are different upon the two sides of the 
thorax. 

The left interscapular region, in addition to the left lung, con- 



CLINICAL ANATOMY OF THE THORAX 51 

tains a portion of the left bronchus; and, near the midspinal line, 
the descending thoracic aorta, the esophagus, and the thoracic duct. 
The right interscapular region overlies the right lung and right 
bronchus in a portion of its course. The trachea extends downward 
in front of the bodies of the thoracic vertebrae from its junction 
with the larynx opposite the sixth cervical vertebra to the fourth 
dorsal vertebra, where it bifurcates to form the bronchi. The 
tracheobronchial glands are clustered about the angles formed by 
the bifurcation. 



SECTION II 

PHYSICAL EXAMINATION OF THE RESPIRATORY 

ORGANS 



CHAPTER II 



INSPECTION 



Object and Technic. — In the study and analysis of disease of 
the respiratory organs, inspection is employed to determine the 
condition of the surface of the thorax, various unilateral and bi- 
lateral variations from the normal contour and size of the thorax, 
the presence of local prominences and depressions, the character 
and frequency of the respiratory movements of the thorax, the 
relative and absolute degree of expansion of the two sides, the 
presence of local abnormal pulsations upon the surface of the 
thorax, and in fluoroscopic study of the thoracic viscera. 

During inspection of the thorax the clothing should be removed 
to the waist, as a full and direct exposure of the chest is essential 
to a proper examination by all the methods employed in physical 
diagnosis. During the routine examination the erect posture, with 
the patient seated or standing, is preferable. During the inspection 
of the thorax, as in all physical examinations, the attitude of the 
patient should be natural and unconstrained. In the routine in- 
spection of the front of the thorax the arms should hang naturally 
at the sides. During inspection of the lateral regions of the thorax 
the hands should be clasped behind the head, allowing a free ex- 
posure of the axillary and infraaxillary regions. In examining a 
patient in the erect posture, the examiner should view the chest 
from the front, from the sides, and from behind the patient. Finally, 
he should assume a position above the patient and look downward 
over the shoulders of the patient. In the event that it is necessary 
to examine a patient in the recumbent posture, the thorax should be 
inspected from below, the examiner assuming a position near the 
feet of the patient, as well as from above, the examiner standing 
near the head of the patient, with the patient in such posture as to 

52 



INSPECTION OF RESPIRATORY ORGANS 53 

allow a free exposure of the lateral and anterior regions of the 
thorax. Moreover, in such event, the patient must be turned a 
sufficient number of times during the examination to insure the 
inspection of all portions of the thorax. The element of position of 
the patient is one of the most important factors which enter into 
physical examination, as a faulty or constrained attitude upon the 
part of the patient is a fruitful source of erroneous conclusions 
upon the part of the examiner. 

During the examination of the patient in the erect posture the 
light should, in the first instance, fall directly upon the area under 
examination, the source of illumination preferably passing over the 
left shoulder of the examiner. After having inspected the thorax 
by direct illumination, the same procedure should be observed with 
the patient exposed to oblique illumination. The latter method 
of examination will often reveal a patch of deficient expansion so 
slight as to have escaped detection during the examination by direct 
light. The preferable source of illumination in all cases is day- 
light, as artificial illumination, aside from altering the appearance 
of any pigmentation that may be present upon the surface of the 
thorax, is apt to produce shadows which may result in erroneous 
conclusions. 

THE CHEST WALL 

Inspection of the chest wall is apt to reveal changes in the con- 
dition of the skin, alterations in the subcutaneous tissues and mus- 
culature, changes in the superficial vessels of the thorax, changes 
in the mammary gland, or abnormalities of the ribs and intercostal 
spaces. 

The skin of the thorax in health is smooth and glossy and is 
lubricated with an adequate amount of sebaceous material. The 
skin of the adult male thorax is frequently clothed with a variable 
amount of hair, which is apt to obscure the true state of the skin 
and which may become a source of error in the application of the 
various maneuvers which are employed in the physical examination 
of the thorax. 

The color of the skin varies normally in different individuals. 
Aside from this normal variation in pigmentation, certain diseases 
which are not directly referable to the respiratory organs produce 
more or less characteristic pigmentation of the skin, notably Addi- 
son's disease, syphilis, chronic malarial intoxication, hepatic dis- 
orders, and following herpes zoster ; whereas chlorosis and perni- 
cious anemia lend a greenish or lemon-yellow tint to the skin of the 



54 PHYSICAL DIAGNOSIS 

thorax as indeed to that of the entire body.* In arthritis of long 
standing the thoracic integument is shiny and frequently covered 
with the pustules of acne. In the cachexia of malignant disease it 
is thinned and presents a yellow, straw-colored tint; while in ad- 
vanced chronic phthisis the skin of the thorax is dry, with general 
pallor, and with here and there irregular, yellowish spots of pityria- 
sis versicolor from which it is easy to detach a thin layer of epi- 
dermis. The skin of the thorax is subject to the eruptions of the 
acute, exanthematous fevers ; and the skin of this region not infre- 
quently presents scars, the result of trauma or of syphilis. 

Occasionally the examiner will encounter silvery striae, analagous 
to the striae developing upon the abdomen during pregnancy in 
patients who have suffered from thoracic distention during early 
life and adolescence. The striae are ordinarily situated upon the 
posterior and inferior portions of the thorax and pursue a course 
parallel with the intercostal spaces. They are observed in the 
train of extensive lobar pneumonia, serofibrinous pleurisy with 
effusion, chronic ulcerative phthisis, and pneumothorax. In these 
pathologic states of the thoracic viscera the stride develop upon 
the side opposite the disease process which cripples the corre- 
sponding lung and leads to vicarious distention of the opposite lung 
as a consequence of the compensatory emphysema which develops. 
Gilbert, Troisier, and Menetrier explain their production as the 
result of rupture of the elastic fibers of the deeper portions of the 
thoracic integument along the course of the intercostal spaces, a 
rupture which is especially likely to occur in this class of patients 
on account of the unusual elasticity and resilience of the thoracic 
cage at this time of life. 

The condition of the sul) cut a?ieo us tissues and musculature of 
the thorax is influenced by the state of general nutrition of the 
patient, and varies as this is good, moderately good, or poor. The 
extensive atrophy of these tissues in chronic ulcerative phthisis 
presents a striking contrast with the prominence of the ribs in this 
disease, while a similar wasting of these tissues may be the result 
of chronic pressure from a pleural effusion of prolonged duration. 

The superficial veins of the thoracic wall, scarcely visible in the 
normal subject, become engorged and tortuous when intrathoracic 
lesions interfere with the venous return to the right heart. Thus, 
engorgement of the superficial veins of the thorax is significant of 
compression of the large intrathoracic venous trunks by medi- 
astinal tumor, aortic aneurysm, or excessively hypertrophied heart. 
Similarly, distention of the veins over the lower region of the 



INSPECTION OF RESPIRATORY ORGANS 55 

thorax, communicating with similarly distended veins over the 
abdomen, and not infrequently associated with the caput medusge, 
is indicative of stasis in the distribution of the portal vein and 
inferior vena cava. 

The mammary gland, an imperfecth^ developed and rudimentary 
structure in the male subject, in the presence of pulmonary tuber- 
culosis in this sex has occasionally been observed to undergo an 
extensive hypertrophy. In other instances hypertrophy of this 
gland in the male sex is congenital and devoid of diagnostic signifi- 
cance. In the latter event the glandular hypertrophy is commonly 
bilateral. In the female subject, on the contrary, hypertrophy of 
the mammary gland is a normal accompaniment of pregnancy and 
lactation, and enlargement of the gland also attends malignant dis- 
ease. 

Edema of the thoracic wall may be encountered in a general or a 
local form. General edema of the chest wall attends general an- 
asarca. Moderate edema of the thoracic wall, limited to one side of 
the thorax, is almost invariably indicative of suppurative disease 
within the thoracic cavity. When it develops in the course of sero- 
fibrinous pleuris}^ with effusion, it is suggestive of a purulent alter- 
ation of an effusion which has been serofibrinous. When empyema 
is rapidly extending and rupture through the thoracic wall is im- 
minent, there commonly develops a localized, edematous promi- 
nence, usually with moderate discoloration of the integument, 
empyema necessitatis. When this is located upon the left side of 
the thorax, in close proximity to the heart, the contractions of the 
heart are apt to provoke systolic pulsation of the contained puru- 
lent material, with the consequent production of a condition of 
pulsating empyema. 

The intercostal spaces are normally slightly depressed, contrast- 
ing with the adjacent ribs. In the presence of wasting of the 
subcutaneous tissues and intercostal musculature as the result of 
the emaciation of chronic pulmonary tuberculosis, diabetes mellitus, 
or paralysis of the intercostal muscles, the normal depression of the 
intercostal spaces is accentuated, rendering the ribs unduly promi- 
nent. On the other hand, in the presence of extensive pleural 
effusion and in pneumothorax the intercostal spaces upon the af- 
fected side occupy the same plane as their corresponding ribs, in 
marked contrast to the normal depression of these spaces upon the 
opposite side of the thorax. Actual bulging of the intercostal spaces 
is very rarely encountered, save in empyema of extensive duration. 

The W&5, not clearly perceptible upon inspection in the normal 



56 PHYSICAL DIAGNOSIS 

subject save in the lower axillary and infraaxillary regions, in the 
presence of chronic wasting disease become conspicuous landmarks 
upon the surface of the thorax. In rickets, moreover, there is 
permanent deformity at the junction of the ribs and costal carti- 
lages, constituting the rachitic rosary of this disease. 

The course pursued by the ribs is suggestive of certain diseases 
of the respiratory organs. In the alar thorax of chronic ulcerative 
phthisis the ribs pass sharply downward from the vertebral column, 
bending sharply upward to meet the sternum, resulting in a very 
acute subcostal angle. In the barrel chest of hypertrophic emphy- 
sema, on the contrary, the ribs pass horizontally forward from the 
vertebral column with the consequent production of a very obtuse 
subcostal angle. In rickets, moreover, the ribs are compressed 
laterally, with consequent diminution in the lateral diameter of the 
thorax ; and in the pigeon breast the ribs are markedly compressed 
anterior to their angles, resulting in the keel breast of advanced 
rickets. 

The costal cartilages, normally elastic and mobile, with advanc- 
ing age become progressively less resilient through advancing cal- 
cification, limiting the freedom of excursion of the thorax during 
respiration. 

THE SIZE AND SHAPE OF THE THORAX 

The size and shape of the thorax vary greatly in the normal sub- 
ject, and are remarkably perverted from the normal state in a 
number of diseases of the respiratory organs, as well as in certain 
diseases of other origin, and not infrequently as the result of occu- 
pation. Persons who habitually pursue strenuous occupations pre- 
sent a generally overdeveloped thorax, whereas carpenters and cob- 
blers are apt to exhibit the funnel-chest. Similarly, the thorax of 
the person engaged in clerical work is apt to present an elevation of 
the right shoulder, which is quite normal in this instance. More- 
over, in certain diseases, notably in rickets, hypertrophic emphy- 
sema, and chronic ulcerative phthisis, the thorax becomes perma- 
nently fixed in deformity, and a diagnosis is frequently suggested 
during a casual inspection by the characteristic configuration of 
the thorax. 

THE NORMAL THORAX 

The various modifications to which the normal thorax is subject 
can only be recognized after extensive clinical experience. Es- 



INSPECTION OF RESPIRATORY ORGANS 



57 



sentially, the size and shape of the thorax are governed by the de- 
gree of intrathoracic contents, and in the normal subject the thorax 
presents quite a varied picture in different cases. 

Two general types of normal thorax may be distinguished; 
namely, the inspiratory type of thorax of the physically robust sub- 
ject ; and the expiratory type of thorax of the subject of moderate 
physical development. In the latter the thorax is rather shallow 
with moderate anteroposterior flattening in the infraclavicular and 
mammary regions, slightly elongated, and presents a rather acute 
subcostal angle ; whereas in the former the chest is deep, the antero- 
posterior diameter of the thoracic cavity approaching but not at- 




Fig. 13. — Xormal thorax (in respose). 

taining to the dimensions of the lateral diameter, and with quite 
an obtuse subcostal angle. 

In the normal subject the shoulders usually occupy the same level, 
though moderate dropping of one shoulder is not infrequent. The 
clavicles are not unduly prominent ; but moderate depression of the 
supraclavicular and infraclavicular fossae is not incompatible 
with perfect physical well being. The two halves of the thorax 
are seldom perfectly symmetrical, as the right side is usually more 
fully developed than is the left side owing to the greater employ 
ment of the rig-ht arm in ris'lit-handed individuals. 



58 



PHYSICAL DIAGNOSIS 



The sternum of the normal thorax presents a moderate forward 
convexity, which attains its maximum degree in the central portion 
of the bone. At the junction of the manubrium with the gladiolus 
the sternum usually is marked by a transverse ridge, the angle of 
Louis, which corresponds to the level of the second chondrosternal 
articulation. The ensiform cartilage may be depressed or may 
exhibit a moderate forward inclination without possessing unto- 
ward significance. 

In the inspiratory type of thorax there is frequently a moderate 
anteroposterior convexity of the thoracic wall at the junction of 




Fig. 14. — Normal thorax (full inspiration). 



the ribs with their costal cartilages, whereas in the thorax of the 
expiratory type there is apt to be flattening at the costochondral 
articulations over the upper portion of the thorax. 

The normal bony thorax is clothed with a muscular and sub- 
cutaneous tunic of moderate thickness so that the intercostal spaces 
are neither depressed nor unduly prominent. The thoracic skin is 
smooth and is lubricated by a moderate amount of sebaceous 
material. 

Upon cross-section the normal thorax is reniform, with the hilum 
which corresponds to the vertebral column directed posteriorly, the 
transverse diameter exceeding the anteroposterior diameter by 



INSPECTION OF RESPIRATORY ORGANS 



59 



one-fourth in the adult subject. In the thorax of the child this 
relation between the transverse and the anteroposterior diameters 
of the cavity does not obtain, as the infantile thorax is almost circu- 
lar upon section. 




Fig. 15. — Normal thorax (full expiration). 




Fig. 16. — Cross section of normal thorax. 



DEFORMITIES OF THE THORAX 

Deformities of the thorax may be congenital; they may be the 
result of occupation ; or they may be caused by pulmonary or by 
constitutional disease. In the main, deformities of the thorax, if 
not due to congenital maldevelopment or to rickets, are caused by 



CO PHYSICAL DIAGNOSIS 

obstruction of the upper respiratory passages by hypertrophied 
tonsils or adenoid vegetations, in children; while deviations from 
the normal contour of the thorax in the adult, on the contrary, are 
caused by, and are secondary to, pathologic changes in the thoracic 
viscera, such as collapse or fibroid retraction of a lung, excessive 
inflation of the lungs by hypertrophic emphysema, the presence of 
aneurysm of the thoracic aorta, excessive cardiac hypertrophy, or 
the development of an intrathoracic neoplasm. From these con- 
siderations, it follows that deformity of the thorax may be bilateral, 
unilateral, or local, depending upon the nature of the underlying 
etiologic factors. 

Bilateral Deformities 

The Emphysematous Thorax (Barrel-chest). — In hypertrophic 
emphysema the thorax presents characteristic deviations from the 
normal contour, constituting the barrel-chest of this disease. The 
thorax is increased in all of its diameters, but particularly in the 
anteroposterior diameter, which in marked contrast to the normal 
thorax, exceeds the transverse diameter. The thorax is thick and 
relatively short, and is maintained in a position of distention which 
exceeds that which normally obtains at the completion of full in- 
spiration. The thorax upon cross section is almost circular, with 
the maximum degree of enlargement corresponding to the level of 
the central point of the sternum. 

The thorax presents the greatest degree of distention in the up- 
per and central portions, for the reason that the chronic catarrhal 
inflammation of the smaller bronchioles throughout the voluminous 
bases presents an obstacle to the free ingress of the inspired air 
to these portions of the lungs, whereas the apices and anterior bor- 
ders of the lungs expand compensatorily. For the same reason, the 
excursion of the diaphragm during respiration is limited, throwing 
an increased burden upon the upper intercostal muscles and the ac- 
cessory muscles of respiration, all of which tends to accentuate the 
discrepancy between the expansion of the upper and lower halves 
of the thorax. However, owing to the acquired rigidity of the 
costal cartilages in the emphysematous thorax, there is little ex- 
pansion of the chest ; but in compensation for this deficiency on the 
part of the normally resilient costal cartilages, the thorax during 
respiration rises and falls en masse. 

The ribs in the upper half of the thorax pass almost horizontally 
forward from the vertebral column to meet the sternum, while the 
normal obliquity of the lower ribs is likewise diminished, resulting 



INSPECTION OF RESPIRATORY ORGANS 



61 



in a very obtuse costal angle, and a corresponding increase in the 
outlet of the thorax. Owing to the horizontal course of the ribs 
and the general distention of the thorax, the intercostal spaces are 
abnormally wide, and peculiarly hard and unyielding upon palpa- 
tion. Not infrequently there is visible retraction of the lower 
intercostal spaces during inspiration. 





^-f^o 



Fig. 17. — Emphysemic chest. (Front view.) 



62 



PHYSICAL DIAGNOSIS 



As a rule, the sternum occupies the same plane as the costal 
cartilages, without noticeable bulging or recession, though the 
bone is not infrequently bent slightly at the junction of the manu- 
brium and gladiolus, resulting in an unduly prominent angulus 
Ludovici. 

The scapulffi are closely applied to the back of the bony thorax. 
The normal dorsal curve of the vertebral column is accentuated. 




Fig. 18. — Emphysemic chest. (Ivateral view.) 



INSPECTION OF RESPIRATORY ORGANS 



63 



simulating kyphosis in the extreme case. The clavicles are ele- 
vated, and the neck is short and thick, often with conspicuous 
engorgement of the cervical veins. The sternomastoids are un- 
duly prominent and the head is slightly thrown backward in the 
effort to bring the accessory muscles of respiration into play. 

The condition of the supraclavicular and infraclavicular fossae 
is variable. Frequently these spaces have disappeared and the 
integument occupies the level of the clavicle or even presents a 
local bulging. 

Kyphosis acquired during laborious occupations or developing 
as the result of dorsal caries may be mistaken for the barrel-chest 
of emphysema, as may also thoracic distention due to malignant 
disease of the thoracic viscera, or thoracic deformity due to ex- 
tensive pleural effusion or to enlargement of the liver or of the 
spleen. 

The Phthisical Thorax (Alar, Pterygoid, or Paralytic Thorax). 
— The phthisical thorax presents a marked contrast to the em- 
physematous chest. In the phthisical thorax the anteroposterior 




Fig. 19. — Cross section of emphysematous thorax. 

diameter is greatly diminished, and the thorax is long and fiat, 
presenting a picture of extreme emaciation, owing largely to 
wasting of the pectoral and deltoid muscles. The clavicles stand 
out prominently, in striking contrast to the deep recession of the 
supraclavicular and infraclavicular fossag above and below the 
bones. 

The inner borders of the scapulae stand out upon the posterior 
thoracic wall like wings, hence the name ^'alar thorax" which is 
frequently applied to this type of thoracic deformity. The wing- 
like scapulae enjoy an abnormal mobility upon the posterior 



64 



PHYSICAL DIAGNOSIS 



thoracic wall, owing to atrophy of the investing musculature. 
The shoulders, which seldom occupy the same level, are inclined 
forward, while the head habitually droops anteriorly. 

The ribs pursue a very oblique course downward from the 
vertebral column and bend sharply upward in front of their 
angles to meet the sternum, producing a very acute subcostal 
angle. The intercostal spaces are wide ; and the intercostal muscles 
are wasted, yielding readily to palpation with the finger-tips. The 
elongated, flat thorax is surmounted by a long, tapering neck in 




Fig. 20. — Phthisical thorax. 



which the sternomastoid muscles and the larynx stand out promi- 
nently. 

The phthisical thorax in its full development is one of the signs 
of chronic ulcerative phthisis. In its partially evolved form it is 
encountered in inanition and in subjects with a predisposition to 
phthisis. 

The Rachitic Thorax. — Advanced rickets is accompanied by a 
characteristic deformity of the thorax:. In this type of thoracic 



INSPECTION OF RESPIRATORY ORGANS 



65 



deformity the anteroposterior diameter is increased, while the 
lateral diameter is diminished as the result of muscular action 
upon the abnormally yielding ribs, causing the sternum to jut 
forward and to assume an unduly prominent position. A cross 




V^WvvV^ 



1 



Fig. 21. — Phthisical thorax. (Anterior view.) 



section of the rachitic chest shows a marked increase in the 
anteroposterior diameter with an actual decrease in the trans- 
verse diameter of the thorax. 



66 



PHYSICAL DIAGNOSIS 



At the junction of the ribs with their costal cartilages the 
rachitic thorax presents a series of nodular swellings, due to en- 
largement of the osteocartilaginous junctional tissues, the rachitic 
rosary. As a result of the lateral compression of the thorax, the 




Fig. 22. — Phthisical thorax. (Lateral view.) 

costal angle is abnormally acute. Not uncommonly the lower 
ribs flare outward anteriorly. The rachitic thorax is attended 
by various types of spinal curvature, as kyphosis, lordosis, or 
scoliosis. 



INSPECTION OF RESPIRATORY ORGANS 



67 



The rachitic chest is not significant of any disease of the res- 
piratory organs; but the compressed thorax is not sufficiently 
capacious for the lungs to properly expand and to attain their 




Fig. 23. — Phthisical thorax. (Posterior view.) 

full development, and hence this type of thoracic deformity pre- 
disposes to disease of the organs of respiration. 

Harrison's Sulcus. — Harrison's sulcus is a groove or depression 
extending downward and outward upon either side of the thorax 



68 



PHYSICAL DIAGNOSIS 



from the ensiform cartilage toward the infraaxillary regions. 
It is often a sign of early rickets ; it almost invariably accompanies 
the rachitic thorax ; and it is also caused in early life by obstructive 
lesions of the upper air passages, in which event it is to be at- 
tributed to the external atmospheric pressure compressing the soft 
ribs which are not supported by full -inflation of the lungs. The 
deformity is particularly common in the negro race. 

The Pigeon-Breast. (Keel-Breast: Pectus Carinatum). — In 
this type of thoracic deformity the ribs are compressed and 
straightened in front of their angles, causing the sternum to jut 
forward and to become unduly prominent. Upon cross section 
the thorax is roughly triangular. The anterior portion of the 
thoracic cavity is encroached upon by the incurvation of the ribs. 




24. — Cross section of rachitic thorax. 



25. — Cross section of pigeon breast. 



while the posterior j)ortion of the cavity is compensatorily 
voluminous. Harrison's sulcus is frequently present upon the 
lateral regions of the thorax. 

The pigeon-breast occurs most frequently in cases of advanced 
rickets ; but it may also be produced by the paroxysms of pertus- 
sis or by greatly hypertrophied tonsils during early life. 

The Funnel-Chest. — In this type of thoracic deformity the 
lower end of the, sternum is depressed, the hollow or depression 
occasionally extending as high as the third rib. The funnel-chest 
is in the vast majority of instances a congenital deformity; it 
has. been noted in connection with advanced rickets; and it 
occasionally develops as the result of an occupation which re- 
quires the application of an instrument constantly against the 
lower portion of the sternum as in the case of the cobbler or the 



INSPECTION OF RESPIRATORY ORGANS 



69 



carpenter. The funnel-chest is not essentially a sign of pulmo- 
nary disease ; but, by decreasing the capacity of the thorax, it pre- 
disposes to disease of the bronchopulmonary system. 

Deformity of the Spine. — Kyphosis, lordosis, and scoliosis are 
noted as part and parcel of the thoracic deformities attending 




Fig. 26. — Kyphosis due to vertebral caries. 



rickets. Lateral deviation of the spine is noted in the presence 
of large pleural effusions, extensive empyema, and in the presence 



70 PHYSICAL DIAGNOSIS 

of intrathoracic neoplasm. In vertebral caries kyphosis is a fre- 
quent finding. 

Unilateral Deformities 

Unilateral Enlargement. — Enlargement or bulging of one side 
of the thorax is caused by an increase in the size of the visceral 
content of the corresponding side, or by the presence of abnormal 
material, which may be air, gas, serum, pus, or blood. The en- 
largement may be significant of compensatory emphysema of one 
entire lung, arising as the result of vicarious distention of the 
lung to compensate for crippling of the opposite lung by cavita- 
tion, compression, or fibrosis, in which event the retraction of the 
diseased side of the thorax adds materially to the apparent bulging 
of the emphysematous side. The presence of air or gas in the 
pleural cavity in open or closed pneumothorax produces uni- 
lateral bulging of varying degree. The compression of the lung 
in these cases also results in compensatory emphysema of the 
opposite lung; but the latter does not attain such a degree as to 
equalize the enlargement of the two sides of the thorax. Exten- 
sive pleural effusion, hemothorax, empyema, and hydrothorax 
cause similar disproportion between the two halves of the thorax ; 
and in these cases, in which the enlargement is due to the presence 
of fluid, the bulging is most pronounced in the lower portion of 
the thorax; the costal angle is rendered more obtuse; and the 
intercostal spaces occupy an equal plane with the ribs or show 
slight bulging. 

In unilateral enlargement of the thorax the circumference and 
anteroposterior diameter of the affected side are increased, and 
the intercostal spaces are wider than normal. The shoulder upon 
the affected side is slightly elevated, and the vertebral column 
deviates toward the side of the bulging. 

Unilateral Diminution. — Diminution of the size of one-half of 
the thorax is indicative of a corresponding diminution in the size 
of the intrathoracic contents upon the affected side. Chronic 
pulmonary tuberculosis of the corresponding lung is the most 
prolific cause of this deformity. In other instances it is due to 
bronchial obstruction with subsequent collapse of an extensive 
portion of the lung. Fibrosis of the lung in the course of chronic 
interstitial pneumonia, fibroid phthisis, and pulmonary syphilis 
results in unilateral retraction or fiattening of one side of the 
thorax. A further causative factor in the production of this 
type of thoracic deformity is the traction of adhesions which bind 



INSPECTION OF RESPIRATORY ORGANS 71 

the visceral to the parietal pleura, or total obliteration of the 
potential pleural cavity, the result of chronic adhesive pleurisy. 

All of these conditions are attended by compensatory emphysema 
of the opposite lung, thus accentuating the disproportion between 
the two sides of the thorax. In this deformity the circumference 
of the affected side is diminished, as is the anteroposterior di- 
ameter; whereas the Jransverse diameter is increased. In cases 
due to chronic pulmonary tuberculosis, the retraction is most 
marked upon the upper half of the thorax; whereas in cases de- 
pendent upon chronic adhesive pleurisy the deformity is most 
noticeable over the lower thoracic region. 

In addition to the diminution in the size of the affected side, 
the corresponding shoulder droops, and the vertebral column 
deviates, with its concavity directed toward the retracted side. 
This curvature of the spine is apt to prove a source of error in 
the casual examination of cases iDresenting minor degrees of uni- 
lateral retraction, as lateral spinal curvature from other causes 
may simulate unilateral diminution of the thorax in its absence. 
The intercostal spaces upon the retracted side of the thorax are 
narrowed ; and, in cases of extreme retraction, the ribs may actu- 
ally overlap in the lower thoracic region. 

Local Deformities 

Local deformity of the thorax may have reference to changes 
in the organs of respiration or to alterations in the circulatory 
system. Those which are referable to the former possess a vari- 
able significance, depending upon the location upon the thoracic 
surface in which they occur and upon their general physical char- 
acteristics. 

Local Prominence. — Upon the anterior or lateral thoracic wall 
a local prominence is indicative of a localized serofibrinous pleur- 
isy; a large neoplasm of the mediastinal structures, lung, or chest 
wall; or of a large pulmonary cavity which is filled with fluid. 
A local prominence Avhich is associated with edema or discolora- 
tion of the integument of the thorax signifies empyema neces- 
sitatis. Rarely congenital diaphragmatic hernia is responsible 
for local prominence of the chest wall. Undue prominence of the 
sternum, when not caused by aneurysm of the aortic arch, is fre- 
quently due to malignant disease of the mediastinal glands. Local 
prominence of the left hypochondriac region points to splenic 
enlargement, while a similar enlargement over the right hypo- 



72 PHYSICAL DIAGNOSIS 

chondriac region is indicative of hepatic efilargement or of a low 
right-sided pleural effusion. 

Upon the posterior thorax a local prominence in the median 
line, overlying the vertebral column, accompanies vertebral ca- 
ries and spina bifida; while upon either side of the median line 
in the paralytic thorax the inner borders of the alar scapulae 
stand out prominently. 

Local Retraction. — Undue depression of the supraclavicular 
and infraclavicular regions, with unduly prominent clavicles, 
points in the first instance to apical pulmonary tuberculosis, 
and secondarily to fibrosis of the lung or to traction by pleural 
adhesions. Local retractions upon the anterior thoracic w^all, 
adjacent to the lateral sternal borders, frequently indicate pul- 
monary excavation due to chronic ulcerative phthisis or to 
bronchiectasis ; while a circumscribed area of flattening or of 
moderate depression upon the posterior Avail of the thorax ac- 
companies pulmonary abscess. Local retraction over the lower 
portion of the sternum constitutes the essential feature of the 
funnel-chest, whereas upon the lateral walls of the thorax Harri- 
son's sulcus is frequently noted in rachitic patients. As a general 
rule, local retractions in the lower anterior and lateral thoracic 
regions are the result of traction by pleural adhesions. 

Movements of the Thorax 

A study of the movements of the thorax in health and in dis- 
ease constitutes an important part of every physical examination. 
These movements are influenced by the rate, rhythm, and the 
type of respiration obtaining in a given case; and the movements 
are influenced and modified by disease arising within the thorax 
or in other portions of the body. Observation of the thoracic 
mobility reveals the degree of expansion of the thorax, as well 
as the diaphragmatic phenomenon of Litten. Finally, circum- 
scribed mobility of the thorax is noted in the form of normal and 
abnormal pulsations. 

Respiratory Movements of the Thorax. — The respiratory move- 
ments of the thorax comprise an inspiratory excursion and an 
expiratory recession, the latter being followed by a slight pause 
during which the thorax is in a state of repose. The inspiratory 
movement is an active process, which is initiated and executed 
by muscular contraction ; whereas the expiratory recession is a 
passive movement, the thoracic walls receding upon the cessation 



INSPECTION OF RESPIRATORY ORGANS 



73 



of the muscular action. Of the two phases, the expiratory reces- 
sion is of longer duration than is the inspiratory excursion. 

The frequency of the respiratory movements of the thorax in 
health varies Avith the age and sex of the subject. In the normal 
adult the frequency is fourteen to eighteen respirations per 
minute. In the newly born, on the contrary, the respiratory rate 




Fig. 27. — ^Ulustrating the movements of the diaphragm and thoracic and abdominal 
walls, as well as ^the change in position of the intrathoracic and intraabdominal viscera, 
during respiration of the abdominal type. The movements are from the solid lines on 
expiration to the broken lines on inspiration. (Pottenger, after Hasse.) 



is approximately forty-four to the minute, while at five years of 
age it averages twenty-six respirations per minute. The respira- 
tory rate in the female subject is normally slightly in excess of 
that which obtains in the male. 

The character of the respiratory movements of the thorax also 



74 



PHYSICAL DIAGNOSIS 



varies with the age and sex of the subject, an^ two types of normal 
respiration are recognized; namely, the costal type, and the costo- 
ahdominal type of respiration. 

In the adult female subject and during childhood the costal type 
of respiration obtains, in which the thoracic movement is much 
more conspicuous than is that of the abdomen. In this type of res- 




Fig. 28. — Showing the movements of the diaphragm and thoracic and abdominal walls, 
as well as the change in position of the intrathoracic and intraabdominal viscera, when 
combined thoracic and abdominal breathing are pronounced. The movements are from 
the solid lines on expiration to the broken lines of inspiration. (Pottenger, after Hasse.) 

piration the upper portion of the thorax, above the level of the 
third rib, shows the maximum degree of expansion, the lower thor- 
acic region expanding less conspicuously; hence the name ''upper 
thoracic type" which is sometimes employed to describe it. The 
diaphragm participates in but a minor degree in this movement so 



INSPECTION OF RESPIRATORY ORGANS 75 

that there is little or no noticeable epigastric bulging during in- 
spiration. 

In the adult male subject, on the contrary, the respiration is of 
the costoabdominal type, in which the maximum expansion is noted 
over the lower thorax and the upper abdomen. The diaphragm 
is a prime factor in the execution of this type of respiration, and 
by virtue of its descent during inspiration, this phase of the res- 
piratory cycle is marked by excursion of the lower thoracic walls 
and epigastric bulging, while the costal angle becomes more ob- 
tuse. At the same time the sternum is elevated ; the ribs assume a 
more horizontal position ; and there is an increase in both the 
anteroposterior and the transverse diameters of the thorax. 

Yet while these distinct types of normal respiration obtain in 
the two sexes, an exaggeration of either the costal or the costo- 
abdominal type, or the substitution of the one for the other, is 
abnormal; and such alteration possesses definite diagnostic signifi- 
cance. Thus, exaggeration of the costal type of respiration in the 
female subject or the presence of this type in the male is indicative 
of immobilization of the diaphragm by subphrenic pressure or of 
paralysis of this important muscle. Excessive subphrenic pressure, 
preventing the descent of the muscle during inspiration may be due 
to ascites, large abdominal tumor, tympanites, or peritonitis. 

Similarly, accentuation of the costoabdominal type of respiration 
in the male or its presence in the female subject points to prema- 
ture calcification of the costal cartilages or scleroderma, destroying 
the normal elasticity of the upper thorax ; or it may signify inhibi- 
tion of thoracic excursion due to the pain of an acutely inflamed 
pleura, of pleurodynia, or of a recent fracture of a rib. Such a 
reversal of the normal type of respiration is also noted in the pres- 
ence of extensive disease of the thoracic viscera, notably in massive 
pneumonia, bilateral pleurisy with effusion, pulmonary tubercu- 
losis, or pulmonary neoplasm. 

The Diaphragmatic Phenomenon (Litten's Sign). — At the com- 
pletion of expiration the upper surface of the diaphragm is in 
apposition with the lateral walls of the thoracic cavity from the 
seventh to the tenth ribs. During inspiration the diaphragm, 
which at the completion of expiration is in close apposition with 
the chest wall in its lower portion, becomes separated from the 
thoracic parietes gradually and progressively in its descent. The 
gradual separation of the two apposed surfaces during inspiration 
causes a slight undulation or ''shadow" to pass downward upon 
the lateral thoracic walls from the seventh to the tenth ribs when 



76 PHYSICAL DIAGNOSIS 

the patient is exposed to oblique illumination. During expira- 
tion, as the diaphragm in its ascent again adapts itself to the 
chest wall, there is an ascending undulation in the same area, 
which, however, is not as readily perceptable as is the descending 
^^ shadow" which occurs during inspiration. 

To elicit Litten's sign the patient is placed in the dorsal posture 
with the head comfortably elevated, and with the hands clasped 
above the head, with the feet directed toward the source of illu- 
mination, preferably an open window, the light from which 
should fall obliquely upon the side under observation. The 
examiner assumes a position near the feet of the patient, with his 
back toward the source of illumination; whereupon in a normal 
thorax the undulation is perceived to descend for the space of two 
inches or more during inspiration and, under favorable circum- 
stances, to ascend to an equal degree during expiration. 

Restriction of, or abolition of the "shadow" points to an ab- 
normal condition within the thorax or abdomen which interferes 
with the free excursion of the diaphragm or to paralysis of this 
muscle. In the thorax it may signify pneumothorax, pneumonia, 
pleurisy with effusion, adhesions between the visceral and parietal 
pleura, hypertrophic emphysema, intrathoracic neoplasm or pul- 
monary tuberculosis, interfering with the proper inflation of the 
lungs. In the abdomen abolition of the undulation may be indic- 
ative of increased subphrenic pressure from hepatic or splenic 
enlargement, subphrenic abscess, ascites, or large abdominal tumor. 

Pathologic Respiratory Variations.— In the presence of disease 
of the thoracic viscera and in many instances of disease of distant 
portions of the bodily economy, as well as in numerous constitu- 
tional affections, the respiration presents typical variations from 
the normal rhythm and type. The predominant change may 'be 
an increase or a diminution in the frequency or depth of respira- 
tion, or it may consist in a prolongation of one or the other phase 
of the respiratory cycle. In other instances the respiration be- 
comes stridulous, sterterous, or it assumes the meningeal or 
Cheyne-Stokes type. In yet other instances the respiration be- 
comes so labored as to be distinguished as dyspnea or orthopnea, 
which may or may not be attended by cyanosis. 

Rapid Respiration (Polypnea) .^Simple increase in the rate of 
the respiratory movements of the thorax is observed as a result 
of active physical effort, during mental and emotional excitement, 
and not infrequently is induced by the consciousness on the part 
of the patient of the examination, without possessing untoward 



INSPECTION OF RESPIRATORY ORGANS 77 

significance. Febrile movement is attended by polypnea, as are 
certain forms of cerebral disease and hysteria. Pulmonary lesions 
which decrease the air space of the lungs as do the consolidations 
of pneumonia and tuberculosis; compression of the lung by 
pneumothorax, pleurisy with effusion, or mediastinal tumor ; and 
elevation of the diaphragm by subphrenic abscess, ascites or ab- 
dominal neoplasm ; all result in acceleration of respiration. Dur- 
ing imperfectly compensated valvular heart disease the respira- 
tions are rapid; and during the course of diabetes mellitus and 
uremia elevation of the respiratory rate of varying degree is 
noted. 

Slow Respiration (Oligopnea). — Diminution of the respiratory 
movements of the thorax, the number falling below fourteen 
respirations in the minute, is observed in states of collapse and 
in the coma of uremia or diabetes. Increased intracranial pres- 
sure from tumor, abscess, hemorrhage, or meningitis is attended 
by an abnormally slow respiratory rate. The respiratory move- 
ments are also diminished during the course of infectious diseases 
which are associated with mental torpor. In these states, in addi- 
tion to the diminution in the frequency of the respiratory move- 
ments, the rhythm of the respiration is usually disturbed. 

Prolonged Inspiration. — Inspiration is unduly prolonged in 
tracheal and laryngeal obstruction from spasm, compression, 
new growth, or foreign body. In these states the lower inter- 
costal spaces and the upper abdomen are retracted during the 
violent inspiratory effort. 

Prolonged Expiration. — The expiratory phase of the respira- 
tory cycle is unduly prolonged in hypertrophic emphysema and in 
bronchial asthma, the muscles of expiration being called into 
play in the effort to expel the tidal air from the lung, substituting 
an active for a passive process. In the paroxysm of bronchial 
asthma, in addition to the prolongation, expiration is dotted with 
numerous rales. 

Stertorous Respiration (Snoring Breathing). — During the coma 
of uremia, diabetes, and apoplexy respiration is frequently at- 
tended by stertor. The same type of respiration is frequently 
noted in cases of palatal paralysis. Less frequently stertorous 
respiration is encountered in the presence of large postpharyngeal 
abscess, with extensive adenoid vegetations in the nasopharynx, 
in chronic tonsillar hypertrophy, and in quinsy. Aside from 
these local causes, stertorous respiration is frequent in the coma 



78 PHYSICAL DIAGNOSIS 

■ * 

resulting from poisoning from illuminating gas, alcohol, opium, 
or other narcotic drug. 

Stridulous Respiration (Hissing Breathing). — Stridulous res- 
piration is indicative of laryngeal or tracheal obstruction by 
infiltration, compression, new growth, or foreign body. It is 
produced by compression of these structures by enlarged glands, 
mediastinal tumor or an excessively hypertrophied heart. Hiss- 
ing breathing also occurs in spasm and edema of the glottis, 
which is apt to develop in the course of syphilis or tuberculosis 
of the larynx, during diphtheria and acute laryngitis, or as a 
complication of one of the acute infectious fevers. Stridor also 
accompanies the paroxysms of pertussis and the attacks of laryn- 
gismus stridulus, the stridor in these instances being more pro- 
nounced during, or entirely limited to, inspiration. The stridor 
of laryngeal obstruction is as a rule accompanied by aphonia. 

Cheyne-Stokes Respiration. — In this type of respiration, follow- 
ing a period of transient apnea, the respirations become progres- 




Fig. 29. — Cheyne-Stokes respiration. 

sively deeper until a maximum depth is attained, whereupon they 
gradually become more shallow to finally terminate in another 
apneic period. The period of apnea lasts from ten to twelve 
seconds as a rule, and during this time the patient is apt to be- 
come unconscious, with cyanosis, slowing of the pulse rate, and 
myosis. Persisting for a period of time varying from a few hours 
to several months, this type of respiration is of grave prognostic 
significance. It is frequently a sign of impending dissolution. 
Associated particularly with cerebrospinal meningitis, cerebral 
tumor, and apoplexy, Cheyne-Stokes respiration is also frequently 
noted during the coma of uremia and diabetes, and more rarely 
with arteriosclerosis and chronic valvular heart disease, and very 
rarely indeed it develops during the course of typhoid fever and 
lobar pneumonia. 

Biot's Respiration (Meningeal Breathing). — In this type of 
pathologic respiration there are periodic interruptions in the 
respiratory sequence, during which the patient is apneic. The 



INSPECTION OF RESPIRATORY ORGANS 79 

periods of apnea vary in duration and recur at irregular inter- 
vals. The periods of apnea lack the definite regularity which is 
noted in Cheyne-Stokes respiration. In addition, there is marked 
irregularity in the depth and rhythm of the individual respira- 
tions. 

Occurring most frequently during the course of meningeal 
inflammation, Biotas respiration is also observed occasionally in 
cerebral hemorrhage and tumor, and during the periods of somno- 
lence of acute infectious fevers. 

Dyspnea 

Dyspnea, difficult or labored breathing, is recognized clinically 
by the increased frequency of the thoracic excursions and by the 
participation of the accessory muscles of respiration in the move- 
ments. Dyspnea may be present in varying grades, ranging from 
a slight increase in the frequency of the respirations to extreme 
difficulty accompanied by blueness of the lips and finger-tips 
(cyanosis). 

Dyspnea may be entirely limited to inspiration, as when the 
air passages are obstructed by a foreign body, or it may be 
expiratory as is the case in hypertrophic emphysema and bron- 
chial asthma. Usually there is present a combination of inspira- 
tory and expiratory dyspnea. 

Dyspnea may arise as a result of deficient aeration of the blood 
content of the lungs arising as a result of an obstruction to the 
free ingress of air to the lungs, the causes of which are indeed 
varied. The obstruction may reside in hypertrophy of the tur- 
binates or in adenoid vegetations in the nasopharynx, retro- 
pharyngeal abscess, or excessive tonsillar hypertrophy. The 
obstruction may reside in the larynx in the form of edema of the 
glottis, spasm of the rima glottidis, cicatricial stenosis from 
syphilitic laryngitis, or from lodgment of a foreign body in this 
portion of the air passages. Inspiratory dyspnea may also be 
caused by partial stenosis of the trachea, occurring as a sequence 
of cicatricial stenosis of the tube of intratracheal origin, or from 
compression of the trachea from without by an enlarged thyroid 
gland, a mediastinal tumor, or aneurysm of the aorta. Similarly, 
inspiratory dyspnea may arise from obstruction of a principal 
bronchus by cicatrix, pleural adhesions, or foreign bodies. 

In all of these states the interference with respiration is in- 
spiratory, as recognized by the prolongation of the inspiratory 
phase of the respiratory cycle. Inspiration is prolonged unduly, 



80 PHYSICAL DIAGNOSIS 

■ * 

frequently with the development of an audible stridor, whereas 
expiration is brief and is attended by little movement of the 
thoracic walls. 

Dyspnea involving principally expiration is noted in subjects 
of hypertrophic emphysema and during the paroxysm of bron- 
chial asthma. In these diseases following upon a fairly rapid 
inspiration, there succeeds an unduly prolonged expiratory phase 
during which the inspired air is ejected tardily and with obvious 
effort upon the part of the subject of the disease. In bronchial 
asthma the expiratory phase is dotted with numerous piping 
sibilant and snoring, sonorous rales. 

When the pulmonary alveoli are filled Avith the consolidations 
of pneumonia or phthisis, and when the lung is compressed by a 
large pleural effusion or mediastinal tumor, dyspnea develops as 
a result of an actual diminution of the aerating surface of the 
lung in which the circulating blood is exposed to the action of 
the aerial content of the lungs. A similar state obtains in the 
presence of extensive effusion into the peritoneum or in the pres- 
ence of a large intraabdominal tumor or marked tympanites, 
conditions in which the diaphragm is displaced upward, partially 
immobilizing the thorax. 

Dyspnea also develops in the presence of extreme weakness of 
the muscles concerned in the respiratory excursion of the thorax 
or with paresis of these muscles. A somewhat analagous state 
obtains when the thoracic excursions are voluntarily inhibited as 
a result of the pain incident to an acute fibrinous pleurisy or a 
fractured rib. 

One of the most ]3roductive causes of dyspnea is to be found 
in valvular heart disease, in Avhich regurgitant lesions of the 
left heart produce passive congestion of the pulmonary circu- 
lation. A similar state is induced by mechanical congestion of 
the lungs, in Avhich the pressure of new growths or enlarged 
glands upon the pulmonary veins retards the flow of blood from 
the lungs to the heart. Under these circumstances dyspnea is 
extreme, amounting to orthopnea. 

Acute infectious fevers associated with toxemia are productive 
of dyspnea, arising from the action of circulating toxins upon 
the respiratory centers. A more serious dyspneic state follows 
upon the action upon these centers of the toxins of uremia and 
diabetes, as evinced by the excessive dyspnea designated as the 
''air hunger" of Kussmaul. 

Primarv or secondary anemia, associated with a marked dimi- 



INSPECTION OF RESPIRATORY ORGANS 81 

niition in the hemoglobin or oxygen-carrying content of the 
blood occasions dyspnea, Avhich may amount in certain cases to 
orthopnea, an extreme grade of dyspnea in which the subject is 
able to breathe only in the erect or sitting posture. 

Cyanosis. — The conditions which result in cyanosis are so 
closely related to the causes of dyspnea, and the two conditions 
are so frequently boncomitant signs of disease of the thoracic 
viscera that the significance of cyanosis may most logically be 
discussed in this connection. The dusky, bluish hue of the integ- 
ument in this condition is due to deficient oxygenation of the 
blood, to which is frequently added a variable degree of venous 
stasis. 

The causes of cyanosis which are referable to the respiratory 
organs may have their site at any point from the upper air pass- 
ages to the remotest ramifications of the bronchioles. Any inter- 
ference with the free ingress of air to the pulmonary parenchyma, 
such as laryngeal or tracheal stenosis from infiltration, pseudo- 
membrane, new growth, compression, or foreign body results in 
deficient aeration of the blood content of the lung and conse- 
quent cyanosis. Conditions which limit the air space of the lungs 
by accumulation within the infundibula or compression of the 
lung from without, result in cyanosis. Cyanosis of varying de- 
gree attends extensive consolidations of pneumonia and tuber- 
culosis in the late stages, as well as edema of the lungs ; whereas, 
a massive pleural effusion, hemothorax, pneumothorax, or large 
mediastinal tumor, by compression and immobilization of the 
lung leads to a similar derangement. 

The principal extrapulmonary cause of cyanosis is to be found 
in valvular heart disease, congenital or acquired, with imperfect 
compensation, particularly when associated with loss of vasomotor 
tone. However, compression of the pulmonary veins by large 
mediastinal tumor, aneurysm of the thoracic aorta, or extensive 
pericardial effusion, acting in a similar manner, results in cyano- 
sis of varying degree. Moreover, the ingestion of excessive doses 
of coal tar products produces cyanosis which may be mistaken 
for cyanosis of pulmonary or cardiac origin. 

Cyanosis may be manifested in varying grades, and it may be 
general or local in its manifestations. General cyanosis is pres- 
ent only in the presence of grave respiratory or circulatory dis- 
ease, or after overdosage with coal tar derivatives. Less extreme 
grades of cyanosis become manifest as local cyanosis, which is 
principally noticeable in the lips, cheeks, buccal mucous mem- 



82 PHYSICAL DIAGNOSIS 

brane, ears, and beneath the finger-nails. *The surface tempera- 
ture of cyanotic areas is invariably reduced. 

Abnormalities of Thoracic Expansion 

Abnormalities in the degree of expansion of the thorax may 
be manifest in the form of bilateral or unilateral variations from 
the normal, or the anomaly may be circumscribed to certain, 
definite areas of the surface of the thorax. The normal degree of 
thoracic expansion is a variably quantity, varying with the de- 
gree of physical development of the individual and with the 
vital capacity of the lungs. The thorax of the athlete exhibits 
a power of expansion greatly in excess of that which is possessed 
by persons who habitually engage in sedentary occupations ; and 
it is only by comparative study of various types of thorax that the 
examiner may form conclusive opinions as to what degree of thor- 
acic expansion is to be considered abnormal in the individual 
case under investigation. 

Bilateral Variations. — Increased general expansion of the 
thorax in all of its diameters is observed after active physical 
effort and during violent emotional excitement without possess- 
ing untoward significance. In hyiDertrophic emphysema, and in 
the course of a paroxysm of bronchial asthma, as well as in 
purely costal respiration due to abdominal disease, a general in- 
crease in the expansion of the thorax is the rule. 

Decreased general expansion of the thorax in its several diam- 
eters is characteristic of the small chest of elderly patients with 
atrophic emphysema. A similar decrease in expansion occurs as 
a result of general muscular weakness and in paralysis of the in- 
tercostal muscles. Obstruction of the upper air passages by limit- 
ing the free ingress of air to the lungs is attended by limitation 
of the thoracic expansion; and bilateral pleurisy with effusion 
and the bilateral consolidation of double pneumonia result in a 
similar diminution of the inspiratory excursion of the chest 
wall. The pain of diaphragmatic pleurisy, pleurodynia, and in- 
tercostal neuralgia causes a general diminution of thoracic ex- 
pansion. Scleroderma affecting the chest wall and premature 
calcification of the costal cartilages result in general limitation 
of expansion. 

Unilateral Variations. — Increased expansion of one side of the 
thorax occurs in the presence of vicarious expansion of one lung 
in compensation for a crippling of its fellow. The cause of the 
imperfect expansion of the unsound lung may reside in the lung 



INSPECTION OF RESPIRATORY ORGANS 83 

itself ill the form of tuberculous or pneumonic consolidation, the 
collapse of atelectasis, or the fibrosis of chronic interstitial pneu- 
monia, fibroid phthisis, or pulmonary syphilis; or, on the con- 
trary, the cause of malfunction may be extraneous to the lung, 
and may assume the form of pulmonary compression by pleural 
effusion, pneumothorax, or mediastinal tumor. 

Decreased expansion of one side of the thorax is noted as a 
consequence of diminution of the air space of the lung by the 
consolidation of phthisis or pneumonia or the fibrosis of chronic 
interstitial pneumonia, pulmonary syphilis, or fibroid phthisis. 
Stenosis of a principal bronchus, resulting in extensive atelectasis, 
leads to diminution or abolition of expansion upon the corres- 
ponding side of the thorax. Pleural effusion, pneumothorax, or 
tumor of the lung or pleura, impairs the thoracic expansion upon 
the side of the disease and results in compensatory expansion of 
the opposite side. Unilateral diaphragmatic paralysis, as well 
as increased subphrenic pressure clue to extensive enlargement 
of the liver or spleen and the traction of pleural adhesions, cause 
limitation of thoracic expansion upon one side. 

Not infrequently the lesion which is responsible for the de- 
ficient expansion produces deformity of the thorax as well, which 
in certain instances is characteristic of the cause. In large 
pleural effusion and in pneumothorax, in addition to the unilateral 
immobilization of the thorax, there is unilateral bulging of the 
chest wall. In limitation of expansion due to pleural adhesions 
and to advanced phthisis, on the contrary, there is apt to be 
unilateral retraction of the thorax. Moreover, a unilateral re- 
traction which is most marked in, or which is limited to, the 
upper thorax is suggestive of j^hthisis, whereas a similar retrac- 
tion of the lower anterolateral thorax points rather strongly to 
postpleuritic adhesions as the cause. 

Local Variations. — Circumscribed areas of increased thoracic 
expansion are encountered over the apices and the bases of the 
lungs, and the location of the vicarious expansion in these cases 
is of potent diagnostic import. Increased expansion over a pul- 
monary apex, limited to the supraclavicular and infraclavicular 
regions, occurs in the consolidation of lobar pneumonia involv- 
ing the lower lobe of the lung, and in compression of the lung 
by pleurisy with effusion, mediastinal tumor, or excessively hyper- 
trophied heart. In the presence of extensive tuberculous con- 
solidation of the apex, on the contrary, the lower portion of the 



84 PHYSICAL DIAGNOSIS 

thorax expands vicariously in compensation for the deficient 
expansion of the upper lobe of the lung. 

Local or circumscribed diminution in the degree of expansion 
of the thorax at the pulmonary apex in the supraclavicular and 
infraclavicular regions is noted in apical pulmonary tuberculosis. 
A similar limitation in expansion of the lower anterolateral re- 
gions of the thorax is commonly due to the traction of pleural or 
of pleuropericardial adhesions. 

Wavy expansion of the thorax is occasionally encountered in con- 
nection with lobar pneumonia, when successive areas of the thorax 
appear to expand in an irregular sequence, one area expanding 
prior to the expansion of adjacent areas. 

Inspiratory retraction of the lower intercostal spaces in the 
lower axillary and infraaxillary regions is a normal phenomenon 
in the first half of the inspiratory phase of the respiratory cycle. 
During the first half of the act of inspiration the interspaces are 
moderately retracted in this area, to become flattened out upon the 
same plane as the ribs during the second half of the respiratory 
act, but never exceeding this level throughout the respiratory 
cycle. Baumler holds that this initial respiratory retraction of the 
interspaces in the normal subject is due to the contraction and 
descent of the diaphragm prior to the contraction of the inter- 
costal muscles, in this wise creating a transitory diminution in 
intrathoracic pressure or a negative thoracic pressure, with the 
result that the atmospheric pressure exerted upon the exterior of 
the thorax during the initial stage of the inspiratory act causes 
recession of the lower interspaces at this time. 

PatJwlogic inspiratory recession of the lower intercostal spaces 
differs from this normal inspiratory recession in the fact that 
the period of the recession consumes the entire time of the act 
of inspiration. The distribution of the retraction possesses defi- 
nite localizing value in these cases. As the obvious cause of the 
retraction in this case is the inability of the lung to become 
fully inflated with air, if the retraction is bilateral, affecting both 
lungs to an equal degree, the seat of obstruction is situated 
above the tracheal bifurcation; whereas, if one entire side of the 
thorax exhibits pathologic inspiratory retraction of the inter- 
costal spaces, the seat of the stenosis is evidently in one of the 
primary bronchi. Circumscribed areas of inspiratory retraction 
signify stenotic lesions of the smaller bronchial tubes. 



INSPECTION OF RESPIRATORY ORGANS 85 

Local Pulsation 

Local areas of pulsation of the thoracic surface possess varied 
significance, depending upon the character and the location of 
the pulsation. A systolic pulsation immediately above the base 
of the heart points to aortic aneurysm. A similar pulsation upon 
the left anterior thorax, between the second and the sixth ribs, 
is frequently a sign of pulsating pleurisy. A local, pulsating 
area overlying the left lung upon the posterior wall of the 
thorax, below the angle of the left scapula, is occasionally due to 
a large pulmonary cavity containing fluid, to which the impact 
of the heart is communicated during ventricular systole. A cir- 
cumscribed pulsation over the low^er anterolateral surface of the 
thorax, attended by local edema of the chest wall, occurs in 
emp3^ema necessitatis when rupture is imminent. 



CHAPTER III 

PALPATION 

Object and Technic. — Palpation is employed in physical exami- 
nation of the organs of respiration to confirm the findings upon 
inspection as to the size and shape of the thorax, the respiratory 
movements, and degree of expansion of the chest, and to detect 
slight deficiencies of expansion which are so slight as to have 
escaped detection during inspection. Palpation is also employed 
in the detection and analysis of several types of vibration or 
fremitus arising in the thorax during health and in diseased 
states. The systematic and skillful practice of palpation also re- 




Fig. 30. — Palpation of anterior thoracic 
surface. 



Fig. 31. — Ulnar palpation of thorax. 



veals the degree of resistance of certain lesions developing with- 
in the thorax, as also the presence of local tenderness, local areas 
of pulsation, and fluctuation. Moreover, palpation yields infor- 
mation as to the tension of the muscular wall of the thorax, the 
presence of local edema, and the condition of the ribs and the 
intercostal spaces. 

As employed in the routine physical examination, palpation 
consists in the application in the first instance of the palmar sur- 
faces of the hands to the surface of the thorax for the purpose 
of appreciating and analyzing variations in the tactile impres- 
sions which are conveyed to the palpating hands. This maneuver 

86 



PALPATION OF RESPIRATORY ORGANS 



87 



is employed in the examination of tlie anterior, lateral, and pos- 
terior regions of tlie thorax. In palpation of the snpraclaA^cular 
and infraclavicular regions, on the contrary, as well as in palpa- 




Fig. 32. — Palpation of upper 
anterior thorax. 



Fig. 33. — Palpation of pulmonar}' apic 





Fig. 34. — Detection of lagging at apices. 



Fig. 35. — Detection of lagging at 
pulmonary bases. 



tion of the intercostal spaces, palpation with the finger-tips alone 
is more serviceable. Certain clinicians recommend the employ- 
ment of the ulnar border of the hand in preference to the palm 
in the practice of palpation; but as a rule, the tactile sensations 



88 



PHYSICAL DIAGNOSIS 



which are appreciated by this portion of the hand are not as fine 
as are those which may be detected by the more sensitive palms. 

During palpation of the thorax the clothing should be removed 
to the waist so that no fabric may intervene between the palms 
of the examiner and the thorax of the subject. 

Palpation may be practiced with the patient in the sitting or 
recumbent posture, preferably in the former; and during exami- 
nations in the recumbent posture it is essential that the patient 
be turned a sufficient number of times to insure palpation of all 
portions of the thorax. In either position the patient should be 
in a state of complete muscular relaxation. The hands of the 




Fig. 36. — Linear palpation of thorax. 



Fig. 37. 



-Palpation of the intercostal, 
spaces. 



examiner should be warm, and they should be applied firmly and 
evenly to the area under examination. 

In testing the expansion of the pulmonary apices the examiner 
should stand behind the patient, and with the index and middle 
fingers in the supraclavicular and infraclavicular regions, re- 
spectively, he should estimate the degree of expansion of the 
apices at the completion of full inspiration. In the detection of 
deficient expansion of the lateral regions of the thorax the ex- 
aminer should assume a position in front oi the patient and 
apply the palms of the two hands to the lower lateral regions 
of the thorax during inspiration. In testing the anteroposterior 



PALPATION OF RESPIRATORY ORGANS 89 

expansion, he should stand beside the patient, and, placing one 
palm upon the middle of the sternum and the other between the 
scapulae, should note the degree of expansion at the completion 
of inspiration. 

Palpation, to be serviceable, must be systematic, the entire sur- 
face of the thorax being gone over in orderly succession and cor- 
responding regions upon the two sides should be compared. Hasty 
and unsystematic palpation is a frequent source of erroneous 
conclusions. 

THORACIC VIBRATIONS 

Palpable vibration of the thoracic Avail (fremitus) is produced 
by the vibrations of the vocal cords during phonation, by the 
movement of the roughened surfaces of an inflamed pleura, by 
the action of coughing, by the forcible movement of fluid in the 
pleural cavity, and during the percussion of the thorax in the 
presence of hydatid cyst. These various forms of tactile fremitus 
are manifested in characteristic manner, and each form furnishes 
valuable data upon which the examiner may base conclusions. 

VOCAL FREMITUS 

Vocal fremitus is manifested in the form of a palpable vibra- 
tion of the thoracic wall, which is conveyed to the palms when 
these are applied to the surface of the thorax during phonation. 
The vibration, which has been likened to the sensation which 
one experiences upon placing the hand upon a resonating box 
in which a tightly stretched wire or cord is caused to vibrate 
rapidly, is appreciated immediately upon the act of phonation. 
Its duration corresponds almost^ but not quite, exactly to the 
duration of the spoken words, the tactile fremitus being pro- 
longed during a very brief space of time after the cessation of 
speech on the part of the subject. 

These vibrations, which originate in the vocal cords of the 
larynx, and which are the physical basis of the production of the 
voice, are communicated directly to the two columns of air situ- 
ated respectively above and below these cords. The aerial column 
situated below the true vocal cords constitutes a continuous con- 
ducting medium throughout the larynx, trachea, bronchi, bron- 
chioles, and pulmonary alveoli, a medium which thus extends to 
the periphery of the lungs. From the pulmonary alveoli the 
vocal vibrations are conducted by way of the alveolar walls and 



90 



PHYSICAL DIAGNOSIS 



the investing pleura to the thoracic walls, and by these walls to 
the palpating hand placed upon the surface of the thorax. 

As the air passages form a closed system, the vibrations aris- 
ing in the vocal cords are naturally conducted downward, since 
the lateral propagation of the waves is effectually prevented by 
the walls of the tubes. Doubtless the solid walls of the air pas- 
sages are also concerned to a minor degree in the conduction of 
the vocal vibrations along their course to the thoracic wall; but 
in this function these structures can play only a minor role, in 
accordance with the physical principle that the transmission of 




Fig. 38. — Normal variations in vocal fremitus. 



vibrations along a solid structure is enfeebled in direct pro- 
portion to the degree of variation in the structure of the conduct- 
ing medium. Certainly the waves of vibration encounter numer- 
ous adverse changes of structure in the course of their conduc- 
tion by way of the solid structures from their origin in the 
larynx to the termination of the finer bronchioles in the periph- 
ery of the lung. 

In eliciting vocal fremitus the examiner should apply the 
palms or the ulnar borders of the hands to the surface of the 
thorax while the patient is directed to count "one, two, three," 



PALPATION OF RESPIRATORY ORGANS 



91 



or to repeat the words ''ninety-nine" in a deep voice of uniform 
intensity, the examiner meanwhile noting the intensity with 
which the vibrations are transmitted to the palpating hand in the 
various regions of the thorax. 

The intensity of vocal fremitus in the normal subject is gov- 
erned by the intensity of the voice during phonation ; by the pitch 
of the speaking voice ; by the variations in the relations of the 
primary bronchi to the thoracic wall; and by the varying thick- 
ness of the thoracic wall in different regions of the thorax. 

The intensity of vocal fremitus varies directly with the inten- 
sity of the speaking voice. Just as the voice is stronger in pro- 




Fig. 39. — Normal variations in vocal fremitus. 

portion as the amplitude of each vibration is greater, so also are 
vocal vibrations of greater amplitude manifested by tactile vibra- 
tions of corresponding intensity. If, during palpation of the 
thorax, the patient is directed to speak continuously in a voice 
of progressively increasing intensity, the resulting vocal fremitus 
will be observed to become progressively more intense. If, on 
the contrary, the speaking voice is so modulated as to become 
progressively less intense, there is witnessed a corresponding 
diminution in the degree of tactile fremitus, which indeed is 
completely abolished when the voice is reduced to a whisper. 
Hence, it is of the first importance during the elicitation of vocal 



92 



PHYSICAL DIAGNOSIS 



fremitus for diagnostic purposes to see that the subject speaks 
in a voice of uniform intensity throughout the examination. 




P'ig. 40-A. — Ukistrating the importance of variations in the thickness of the thoracic 
wall upon the interpretation of physical findings upon palpation of the thorax. 

The pitch of the voice exerts a striking influence upon the 
intensity of vocal fremitus, the tactile vibration being most in- 
tense in subjects with deep, bass voices, and possessing the min- 



PALPATION OF RESPIRATORY ORGANS 



93 




M. ti-apezlu9, 
M. omohyoideiis. 

M. supraspinatus. 

A. Hiibclavia, 

CosU I. 

Clavicula. 

PtANE oy MAXxmRroM Sterm. 

Scapula. 

M. subscapularls. 
Lobus superior pulmonis. 
Incisura Interlobaris. 
M. pectoialis major. 

Lobus laedius pulmonis. 

Transthoracic Plasb. 

Lobus inferior pulmonis. 
Diaphragm 



CosU VII. 
Liver. 

Trakspvloric Pi.a5E; 

Ri;{ht kidney. 

Vesica fellea. (Oall bIa<Wei-.) 
Flexura coli dextnv. (Hepatic flexure. 

Musculatxu-e of alKloniinal parietes. 

Colon transversinii. 

Tran-stvberollar PtASE. 

Intestinum cajcuiu. 
M. gliitjvus inertius. 
Intestinuiii ten lie. 
M. iliacns. 

M. glut;fus iiiiniuius. 
OS cox;e. 



Caput fi'iiiovis, 

51. glutaius iiiaxiiiius. 

Pi.AXK oy Sv.Mi-HYsls Osslu.M Pmis. 

."\I. iliopsoiis. 
V. foiiioralis. 



Fig. 40-B. — Section through body 6 cm. to the right of the median plane, view from 
the right. Showing the importance of the soft tissues as influencing physical examina- 
tion of different areas of the chest. (Pottenger, after Berry.) 



94 PHYSICAL DIAGNOSIS 

■ * 

imum of intensity in subjects of high suprano voices. Indeed 
if, in a suitable subject, the examiner will palpate the thorax 
during phonation of progressively ascending pitch, in the case 
of the high suprano voice, a point will be reached at which the 
tactile fremitus disappears. The underlying physical basis of 
this progressive enfeeblement of vocal fremitus resides in the 
fact that as the pitch of the voice ascends, the sound waves be- 
come progressively more rapid with a corresponding diminution 
in their amplitude, until the point is reached at which palpable 
vibration of the thoracic wall is no longer produced. Upon these 
physical principles it is readily understood that vocal fremitus is 
normally more intense in the adult male subject with his naturally 
deep voice called forth by waves of moderate rate and wide am- 
plitude; and that it is correspondingly less intense in the adult 
female subject and in children, in whom the voice possesses less 
volume but gains in pitch, or, in other words, in whom the sound 
waves possess a more limited amplitude but a higher rate of 
vibration. 

Vocal fremitus in the normal subject is slightly more intense 
upon the right side of the thorax than upon the opposite side, 
because of the greater caliber of the right bronchus and because 
of its anatomical situation in closer proximity to the anterior 
thoracic wall than that of the left bronchus. It follows that 
during phonation a more considerable column of air is set in 
motion in the right bronchus, and its closer relation to the thor- 
acic wall further facilitates the transmission of the vibrations to 
the palpating hand. Vocal fremitus is naturally most pro- 
nounced in those regions of the thorax where the larger bronchi 
approach the thoracic parietes; and it exhibits impairment in 
those areas where the bronchi are separated from the chest wall 
by the intervention of aerated pulmonary tissue. Hence, it pre- 
sents its maximum intensity in the root of the neck, immediately 
over the course of the larynx and the trachea, and is more intense 
over the right apex than upon the corresponding area of the 
opposite side. 

The condition of the thoracic wall exercises a considerable 
influence upon the intensity of vocal fremitus. The deep, mus- 
cular thorax of the robust subject and the thorax which is 
clothed with a thick paniculus adiposus in the obese subject pre- 
sent a striking enfeeblement of the vocal vibrations ; whereas 
these are unduly intense upon palpation of the thin, poorly 
muscled thorax of the emaciated subject, as well as in the thin 



PALPATION OF RESPIRATORY ORGANS 



95 




Costa I. 
Scapula. 
A. subclavia. 

V. suljclaviil. 

ClaviciOa?! 

Plake of Mactbritoi SiERin. 

Lobus superior pulmcmia<; 



Ventriculus sinister. 
Transthoracic Plaise^ 



lobus inferior pulmonis. 

Diapbragina. 

Liver,' 

Pars cardi'aca vehtriculi. (gtomacfr.) 
Glantlula suprarenalis.- 
Left kidney. 

Coi-pus pancreatis. 

Traxspyloric Plaxe. 

Pars pylorica ventrieuli. (Stom£icll.) 

Flexura duodenojejunalis. 

M. sacrospinalif?, (Erector spince-, 

Processus transversua lumbar yertebl^ 
M. psoas major. • 

Intestinunijenue;: 

Musculature of abdominal parietes,' 

Traxsti-bercular Plake.: 
Pars lateralis ossis saori. 
A. iliaca communis sinistra,. 

V. iliaca communis sinistiu. 

Intestinum tenue. 

M. pirifonnis., 

A. ilia'ca externa sillistrit*.,, 

Ramus superior ossis pubis; 

M. obturator internus. 

Pl.AXE OF SyMPH V.SIS OssIUJI PUBtS. ; 

Meiiilirana obtuiutoria. 
M. obturator externus. 
Jr. glut:eus maximus. 
Ramus inferior ossis iscliii. 

Adiluctpr utu5culiitum ' 



Fig. 40-C — Section through body 6 cm. to the left of the median plane viewed from 
the right. Showing the importance of the soft tissues as influencing physical examina- 
tion of different areas of the chest. (Pottenger, after Berry.) 



96 PHYSICAL DIAGNOSIS 

and elastic thorax of the female subject and the child. Exten- 
sive edema and local suppuration of the thoracic wall similarly 
mask the integrity of the tactile vibrations. Upon more minute 
examination, it can usually be demonstrated that vocal fremitus 
is normally more intense over the intercostal spaces than it is 
in the regions which overlie the ribs. It is very natural that the 
intercostal musculature should respond more readily to the in- 
trathoracic vibrations than the less elastic osseous ribs. 

Vocal fremitus presents certain regional variations in the in- 
tensity with which it is transmitted to the palpating hand in 
various regions of the thorax. Considering the thorax as a 
whole, the fremitus in the normal subject is most intense upon 
the anterior thoracic wall; it is slightly less intense upon the 
lateral walls; and it exhibits its minimum of intensity upon the 
posterior wall of the thorax. A number of variations in the 
relative intensity of the fremitus in the normal subject are to be 
encountered upon each of these three aspects of the thorax. 

Upon the anterior surface of the thorax the fremitus is less 
intense in the supraclavicular region, which corresponds to the 
anterior surface of the apex of the lung, than upon any other 
portion of this surface with the exception of the narrow zone im- 
mediately overlying the bony clavicle and over the distribution 
of the mammary gland in the female subject. In the supraclavic- 
ular region the fremitus becomes progressively more intense as 
the examiner palpates inward toward the median line, owing to 
the proximity of the trachea to the inner portion of this region. 

Upon palpation of the narrow zone immediately superjacent to 
the clavicle, the tactile fremitus is greatly enfeebled, contrasting 
in a striking manner with the more pronounced vibrations which 
are encountered in the supra- and infra-clavicular regions above 
and below the bone. But even this limited area of the thoracic 
surface presents certain variations in the intensity of the frem- 
itus, which exhibits its greatest strength upon palpation of the 
inner third of the clavicle, near its junction with the sternum. 
In the middle third of the bone the fremitus exhibits a moderate 
diminution over that of the inner third, a diminution which pro- 
gressively increases in the outer third of the bone as the palpating 
hand approaches the scapula. 

Upon passing from the clavicular area to the infra-clavicular 
region, there is a very appreciable reinforcement of the fremitus. 
This intensity is moderately reduced in the mammary region in 



PALPATION OF RESPIRATORY ORGANS 97 

the male subject, and quite markedly reduced over the mammary 
gland in the female subject. 

In the areas in which the heart and the liver come into direct 
contact with the anterior thoracic wall there is an abrupt cessa- 
tion of vocal fremitus. Linear palpation with the ulnar border 
of the hand is very serviceable in accurately determining the pre- 
cise points at which the fremitus terminates in relation to these 
organs. 

In the median line of the thorax, in the sternal region, at least 
three variations in the intensity of vocal fremitus may be detected. 
In this region the fremitus is most feeble over the upper portion, 
which corresponds anatomically to the manubrium sterni; it at- 
tains its maximum strength over the gladiolus; and it is again 
enfeebled in the lower portion of the region, which overlies the 
ensiform cartilage. 

In the ventral aspect of the neck, in the region in the median 
line which overlies the larynx and trachea, vocal fremitus is 
elicited in its purest form. Even in this restricted region, how- 
ever, certain variations in its intensity may be appreciated by 
careful palpation. Its point of maximum intensity corresponds 
to the level of the inferior border of the thyroid cartilage, from 
which point the vibrations become progressively enfeebled as 
the palpating hand travels upward toward the floor of the mouth 
and downward toward the episternal notch. 

Upon the lateral thoracic walls vocal fremitus is most intense 
in the upper portion of the axillary region, becoming progres- 
sively more feeble as one palpates downward over the lower axil- 
lary and infraaxillary regions. Upon the right side of the thorax 
the fremitus is interrupted abruptly at the upper border of the 
eighth rib by the apposition of the liver with the thoracic wall. 
Similarly, upon the left lateral aspect of the thorax the fremitus is 
interrupted at the upper border of the ninth rib by the apposition 
of the spleen with the thoracic wall. 

Upon the posterior wall of the thorax vocal fremitus presents 
its greatest intensity in the interscapular regions, overlying the 
trachea and its bifurcation to form the two primary bronchi. In 
the subscapular regions, overlying the pulmonary bases, the frem- 
itus undergoes a considerable diminution in intensity by reason 
of the considerable distance of these regions from the site of pro- 
duction of the vocal vibrations. In the regions overlying the 
scapulae the fremitus is more feeble than elsewhere upon the 
posterior thoracic wall, the point of minimum intensity corre- 
sponding accurately to the course of the spine of the scapula. 



98 PHYSICAL DIAGNOSIS 



PATHOLOGIC VARIATIONS 



In the presence of disease of the respiratory organs numerous 
gradations in the intensity of vocal fremitus are encountered. 
As a result of morbid changes in the bronchi, lungs, pleura, or 
thoracic wall, the fremitus may be found to be increased in inten- 
sity, to be diminished in intensity, or to be entirely abolished over 
certain regions of the thorax. In general, affections of the 
pleura are attended by diminution of vocal fremitus, while disease 
of the lungs is manifested by exaggeration of the fremitus; but 
in the interpretation of the findings in any case it is to be remem- 
bered that affections of the bronchi and of the thoracic wall are 
capable of causing either diminution or reinforcement of vocal fre- 
mitus independently of disease of the lung or the pleura. 

Increased Vocal Fremitus. — Vocal fremitus is increased in in- 
tensity in all conditions which are attended by solidification of 
the pulmonary tissues with a concomitant diminution in the air 
content of the area in question. This condition of solidification 
and anaeration obtains in the consolidations of pneumonia, 
phthisis, and hemorrhagic infarction of the lung; in the presence 
of diffuse carcinomatous infiltration of the lung, provided that 
this infiltration does not cause bronchial occlusion; in pulmonary 
atelectasis from external pressure; and in indurative contraction 
of the lung from fibroid phthisis, chronic interstitial pneumonia, 
or pulmonary syphilis. It is essential, however, for consolida- 
tions to yield exaggerated tactile fremitus, that the consolidated 
areas be situated in the periphery of the lung, and that the bronchi 
which terminate in the consolidated areas be free from occlusion. 

The physical basis for the exaggeration of vocal fremitus under 
these circumstances is readily appreciated, since a continuous 
medium of uniform structure conducts vibrations with far greater 
intensity than does a conducting medium which is constantly 
undergoing variations in structure, as are the normal pulmo- 
nary alveoli, in which thin walls of pulmonary tissue constantly 
are interrupted by minute air-containing spaces. When a 
solid neoplasm of the lung occupies the peripheral portion of 
this organ and at the same time extends so deeply into the lung 
as to come into contact with one or more of the larger bronchi, 
the physicar conditions are eminently favorable for the transmis- 
sion of vocal fremitus to the surface of the thorax with the maxi- 
mum degree of exaggeration. 

In the presence of compression of the pulmonary tissues by a 



PALPATION OF RESPIRATORY ORGANS 99 

pleural effusion, the exaggeration of vocal fremitus is ordinarily 
suppressed over the lower portion of the thorax, corresponding 
to the area occupied by the effusion, only to be increased in in- 
tensity in the region immediately above the level of the effusion, 
as a result of compression and relaxation of the pulmonary tissues 
in the upper portion of the pleural cavity. It is quite otherwise 
in the case of pulmonary compression by an extensive pericardial 
effusion. In this instance the compression operates upon the in- 
ternal surface of the inferior lobe of the left lung, leading to 
exaggeration of vocal fremitus over the compressed lobe. Exces- 
sive abdominal distention in ascites, meteorism, or large abdominal 
tumor, can operate in a similar manner, and exhibit exaggeration 
of vocal fremitus over the lower segment of the thorax. 

Pulmonary cavities with free communication with a bronchus, 
when they are situated in the periphery of the lung, are produc- 
tive of exquisite refinements of vocal fremitus. In this case the 
cavity acts as a resonating chamber for the amplification of the 
vocal vibrations. It is essential, however, that the cavity in 
these cases be free from fluid secretion, which may obstruct the 
bronchial orifice and consequently suppress vocal fremitus over 
its distribution. Bronchiectases, when peripherally distributed, 
cause similar exaggeration of tactile fremitus, bronchiectasis be- 
ing the sole affection of the bronchi which is capable of increasing 
the intensity of vocal fremitus. 

. Diminished Vocal Fremitus. — Partial stenosis of the bronchi 
by tenaceous secretions in the course of chronic bronchitis, or 
stenosis arising as a consequence of the lodgment of foreign 
bodies, or of bronchial compression by cicatricial bands, aneu- 
rysm, or extensive pericardial effusion, results in a diminution of 
vocal fremitus over the ultimate distribution of the affected tubes. 
When it is a case of partial occlusion by accumulated secretions, 
the fremitus is occasionally restored in its integrity after a severe 
paroxysm of cough. 

Pleural thickening, sometimes noted at one apex as a result 
of chronic tonsillar infection, as well as in other jDortions of the 
pleural membrane as a sequel of pleural inflammation, is an 
occasional cause of diminution of vocal fremitus. That pleural 
thickening is not invariably attended by diminution of vocal 
fremitus was conclusively demonstrated by Wintrich in his ex- 
periments upon the cadaver. In his experiments he demonstrated 
that upon iuA^esting the exposed pleura with membranes pre- 
pared from the stomach or intestine there was no appreciable 



100 PHYSICAL DIAGNOSIS 

■ « 

change in the intensity of the vocal vibrations when an assistant 
spoke into a tube which was inserted into the primary bronchus 
of the corresponding lung. 

A very important group of cases, a group which is often quite 
confusing to the examiner at the bedside, is composed of certain 
cases of pulmonary infiltration and consolidation which, instead 
of yielding exaggeration of vocal fremitus upon palpation, ex- 
hibit an enfeeblement or abolition of tactile vibrations upon pal- 
pation. This condition is encountered in massive pneumonia, 
in which the terminal bronchi become occluded by fibrinous 
exudate with consequent suppression of vocal fremitus, and 
strongly simulating in this respect the picture of extensive 
pleural effusion. With less frequency, in the presence of carcino- 
matous infiltration of the lung, the neoplastic new productions 
develop in the interior of the bronchi, causing partial or complete 
occlusion of these passages, with consequent diminution or aboli- 
tion of vocal fremitus over the area of the thorax corresponding 
to their distribution. 

When the lung is separated from the thoracic wall by pleural 
effusion or by the accumulation of air or gas in the pleural cavity, 
vocal fremitus is enfeebled or is abolished. In the case of pleural 
effusion, it is possible for extensive adhesions between the visceral 
and the parietal pleura to transmit the vibrations across the ef- 
fusion; and in these cases, also, the fremitus is ordinarily accen- 
tuated over the portion of the lung which is compressed into the 
superior part of the pleural cavity above the level of the effusion. 
It is desirable, but not always possible, in connection with a 
pleural effusion to determine whether the presence of the fluid 
in the pleural cavity is the sole cause of diminution of the frem- 
itus. Occasionally compression of the lung by the effusion results 
in compression and occlusion of the larger bronchi, a factor 
which plays an important part in suppressing the vocal fremitus. 
Moreover, in the presence of extensive effusions the thoracic wall 
is in a state of abnormal tension, which interferes with the trans- 
mission of vibrations arising within the thorax. 

In dealing with pleural effusions, if the upper limit of the area 
of impaired vocal fremitus is carefully marked upon the thorax, 
the examiner is enabled to judge, during consecutive examina- 
tions, of the progress of the malady. In this disease, however, a 
sudden and pronounced descent of the level of the fluid is more 
apt to be due to relaxation of the diaphragm upon the affected 
side than to a sudden and pronounced resorption of the fluid. 



PALPATION OF RESPIRATORY ORGANS 101 

In the case of encysted or loculatecl pleurisy, the examiner can 
occasionally delimit the effusion with fair accuracy by means of 
careful palpatipn with the ulnar border of the hand. However, 
Jaccoud, who has studied multilocular pleurisies with special 
reference to the variations in vocal fremitus, warns the examiner 
against the possibility of error in reaching a diagnosis of encysted 
pleurisy through the findings of palpation alone. 

The accumulation of gas or air in the pleural cavity is at- 
tended by diminution of vocal fremitus over its distribution. In 
the case of pneumothorax limited to the apex of the pleural 
cavity, which yields a tympanitic note upon percussion, the en- 
feeblement of abolition of vocal fremitus over this area is of con- 
siderable aid in the differential diagnosis between a gaseous ac- 
cumulation and a large tuberculous cavity in the apex of the lung. 

In the interpretation of data obtained by the study of vari- 
ations in the intensity of vocal fremitus in the various regions of 
the thorax, it is essential that the examiner be constantly upon 
the alert to detect any changes in the thoracic wall which might 
influence the intensity of the fremitus as appreciated by the pal- 
pating hand. In the presence of atrophy of one great pectoral 
muscle or of the muscles of the shoulder girdle, there is a cor- 
responding exaggeration of vocal fremitus in the corresponding 
region, which might, during a casual examination, suggest the 
presence of apical consolidation. Circumscribed areas of edema 
of the thoracic wall and the presence of peripleuritic suppuration, 
on the other hand, are capable of producing a circumscribed 
diminution of vocal fremitus in the absence of bronchial or pleural 
disease. In the thorax which is the seat of extensive deformity 
from osseous or pulmonary disease deductions should be drawn 
from variations in vocal fremitus with caution and circumspec- 
tion. 

Absence of Vocal Fremitus.— All of the pathologic conditions 
which are capable in the course of pulmonary disease of abolish- 
ing vocal fremitus have been enumerated in the foregoing para- 
graphs. The fremitus is abolished over the circumscribed area 
of the thoracic surface which corresponds to a large pulmonary 
or bronchieetatic cavity which is filled with fluid secretions, 
which deprive the cavity of aerial content and occlude the commu- 
nicating bronchus. A similar circumscribed area of abolished 
fremitus is occasionally encountered at the level of an aortic aneu- 
rysm or over a solid tumor of the lung or pleura which is not in 
intimate relation with a bronchus. 



102 PHYSICAL DIAGNOSIS 

Vocal fremitus is abolished over an extensive area of the lower 
segments of the thorax in the presence of massive pleural effu- 
sion; and over areas of the lung in which the bronchus supplying 
the part has become completely obstructed from any cause. Also, 
in massive pneumonia vocal fremitus may be abolished over the 
area of consolidation as the result of obstruction of the bron- 
chioles and bronchi by fibrinous plugs. 

RHONCHAL FREMITUS 

The term rhonchal fremitus, or bronchial fremitus, was first ap- 
plied by Guttman to the vibrations which are generated by the 
passage of air in the respiratory passages through serum, mucus, 
pus, or blood in the bronchial tubes. The vibrations which are 
thus produced are readily appreciated by the palpating hand ap- 
plied to the thorax. The lesions which are ordinarily responsible 
for the production of rhonchal fremitus are situated in the larger 
and medium-sized bronchial tubes when it is a question of the 
passage of air through tenaceous secretions ; but the lesions which 
are provocative of the fremitus also not infrequently assume the 
form of tuberculous cavities containing fluid with a bronchial 
communication situated below the level of the fluid, through 
which air ascends during inspiration and creates bubbling sounds 
which are transmitted to the thoracic surface in the form of 
rhonchal fremitus. Hence, it follows that rhonchal fremitus may 
possess a variable diagnostic and prognostic signiflcance depend- 
ing upon the mechanism of its production and the region of the 
thoracic surface upon which it is encountered. 

The rhonchal fremitus which originates in the larger and 
medium-sized bronchi in the course of chronic bronchitis and 
bronchial asthma, and which is not of especially grave prognostic 
import, is encountered in the upper sternal, lower infraclavicular, 
and upper mammary regions. Rhonchal fremitus encountered in 
these regions has a very considerable intensity, and it is commonly 
felt over a considerable area of the thoracic surface. Rhonchal 
fremitus which is engendered in a tuberculous cavity, on the con- 
trary, is ordinarily encountered in the supraclavicular and infra- 
clavicular regions, corresponding to the apices of the lungs; it 
has not the intensity of the fremitus generated in the larger 
bronchi; and it is of grave prognostic import. In palpating in 
these regions, the examiner will not infrequently encounter crepi- 



PALPATION OF RESPIRATORY ORGANS 103 

tations which are due to the contractions of the great pectoral 
muscle, particularly when dealing with robust subjects, and 
which may ea'sily be mistaken for rhonchal fremitus. 

Similarly, rhonchal fremitus is apt to be confused with pleural 
friction fremitus. In this connection it is to be remembered that 
in dealing with pleural friction fremitus, the latter is exaggerated 
upon compression of the intercostal spaces ; that pleural friction 
fremitus is ordinarily attended by pain which is exaggerated by 
pressure exerted with the finger-tips in the intercostal spaces; 
and that rhonchal fremitus arising in the bronchial tubes is fre- 
quently abolished by the act of coughing, whereas pleural fric- 
tion fremitus is not influenced by this act. 

Ehonchal fremitus is transmitted to the thoracic surface with 
the maximum intensity in women and children, in whom the 
thoracic wall is thin and elastic, and in the emaciated patient; 
and due allowance should be made for the relative thickness of 
the thoracic parietes in interpreting the intensity of rhonchal 
fremitus in any case in which it is encountered. 



PLEURAL FRICTION FREMITUS 

In the normal subject the visceral and the parietal jDleura are 
moistened by a small quantity of serous fluid which enables the 
membranes to glide over each other during the respiratory move- 
ments of the lungs and the thoracic walls without the production 
of sound. In the iDresence of pleural inflammation, however, the 
surface of the membrane becomes invested by a coating of fibrin- 
ous exudate of varying thickness, by virtue of which there is pro- 
duced during the respiratory movements an audible rubbing 
sound, the pleural friction sound. Upon palpation of the thorax 
over the region of production of the pleural friction sound there 
is frequently encountered a palpable vibration or fremitus, which 
Guttman first designated as pleural friction fremitus. The tactile 
impression which one obtains is that of grating, which is variable 
in intensity in different cases and which is dependent upon the 
respiratory excursions for its generation. It is most frequently 
encountered in the infraaxillary region and the lower mammary 
region; and it is most frequently generated in a vertical direction, 
with less frequency in an oblique direction, and still less fre- 
quently in a horizontal direction. 

The fremitus is appreciated most frequently during inspiration. 



104 physicaIj diagnosis 

with less frequency during inspiration and expiration, and very 
rarely during expiration alone. It is not infrequent that the in- 
tensity of the fremitus is so slight that it is not perceived during 
tranquil respiration, but is brought to the fore by a series of 
deep inspirations. Also, it is not infrequent for the fremitus to 
disappear after a series of deep inspirations, probably by reason 
of the smoothing out upon the pleural surface of the rugosities of 
exudate which called the fremitus into being. At any rate, the 
fremitus frequently reappears upon deep inspiration following 
a period of tranquil respiration on the part of the patient. The 
intensity of the fremitus can be reinforced by pressure upon the 
intercostal spaces in the area of its production, a procedure 
which is attended by exaggeration of the thoracic pain. 

Pleural friction fremitus is encountered in the presence of acute 
fibrinous pleurisy and during the incipient stage of serofibrinous 
pleurisy. In the latter disease the fremitus is present prior to the 
development of the effusion ; it disappears with the free establish- 
ment of effusion ; and it very frequently recurs with partial or com- 
plete absorption or evacuation of the effusion. 



TUSSILE FREMITUS 

Tussile or tussive fremitus is a palpable thoracic vibration 
which is produced upon coughing. It is not invariably present; 
it does not possess great value in physical examination; and it is 
not frequently elicited during the routine physical examination. 
It is to be employed in dealing with patients who are subject to 
aphonia from any cause, when it is not possible to elicit vocal 
fremitus. 

SUCCUSSION FREMITUS 

Succussion fremitus is a palpable thoracic vibration which is 
produced when a patient whose pleural cavity contains air and 
fiuid is suddenly jarred or shaken. Under these circumstances 
the impact of the fluid is felt against the palpating hand as a 
vibration. 

Occasionally extensive pulmonary cavities which are situated in 
the peripheral portions of the lung give the vibration, if they 
contain air and fluid. However, the physical conditions are not 
ideal for the elicitation of this sign from pulmonary cavities; 
and it is much more frequently encountered in hydro-, hemo-, or 
pyo-pneumothorax. 



PALPATION OF RESPIRATORY ORGANS 105 

HYDATID FREMITUS 

In the presence of hj^daticl cyst of tlie lung with visible protru- 
sion of the thoracic wall, it is occasionally possible to elicit hyda- 
tid fremitus by placing the fingers, widely separated upon the 
bulging area and percussing lightly upon one of the fingers. 
Under these circumstances a vibration which is caused by the 
impact of the daughter cysts is occasionally appreciated by the 
fingers. 

CREPITATION 

In cases of surgical emphysema, when the subcutaneous tissues 
of the thorax contain small beads of air, a fine crepitation is often 
demonstrable upon palpation of the affected area with the finger- 
tips. Air maj gain access to the subcutaneous tissues of the thorax 
as a result of trauma or operation upon the neck or chest, or from 
the rupture of dilated infundibula in hypertrophic emphysema. 



LOCAL TENDERNESS 

In the presence of disease of the pleura and in disease of the 
lung complicated with pleurisy, palpation frequently reveals areas 
of local tenderness upon the thoracic surface. The pain in these 
cases is elicited and is also defined by finger-tip palpation of the 
intercostal spaces. Such localized tenderness is suggestive, in 
the first place, of acute fibrinous pleurisy; and Avith less constancy 
it points to intercostal neuralgia, pleurodynia, fracture or caries 
of the ribs, deeply seated disease of the lung, or disease of abdom- 
inal organs. 

Bau and Bouillaud exiDlain the local sensibility of certain in- 
tercostal spaces in connection with acute fibrinous pleurisy on the 
basis of a neuritis of the corresponding intercostal nerves. They 
call attention to the fact that the intercostal nerves in the poste- 
rior third of their course are in direct relation with the under 
surface of the pleural membrane, and Bau has demonstrated mi- 
croscopically that neuritis occurs in connection Avith this pain in 
association with acute fibrinous ]3leurisy and pleuro-pneumonia. 

The fact that the pleural pain is manifested not upon the pos- 
terior thoracic surface, but upon the lateral and anterior aspects 
of the chest is explained by the fact that irritation of the nerve 
trunk is transmitted throughout its terminal expansions. The 
predominance of the pleural sensibility in the sixth and seventh 



106 PHYSICAL DIAGNOSIS 

■ * 

intercostal spaces is due to the fact that this region of the thorax 
is more mobile than other portions, and the extreme mobility of 
these interspaces intensifies the pain npon pressure with the 
finger-tips. 

Malloizel, who has studied pleural pain with special reference 
to interlobar pleurisies, was able in many instances of this dis- 
ease to elicit tenderness which corresponded accurately to the 
course of the interlobar fissure, commencing in the neighborhood 
of the third dorsal vertebra, and radiating toward the lateral and 
anterior thoracic regions along the course of the interlobar fissure 
in question. 

While as a general rule even extensive inflammatory disease of 
the lung is unattended by pain upon pressure exerted in the in- 
tercostal spaces, in pleural inflammation of whatever intensity 
this local tenderness is almost invariably present. However, in 
the case of lobar pneumonia, Hutinel and Paisseau have described 
a submammary painful point in adults, whereas in infants and chil- 
dren the pain is commonly referred to the right iliac region, 
simulating that of acute appendicitis in this class of patients. 

The pain of intercostal neuralgia is not infrequently limited 
to a single intercostal space, but in this space it commonly in- 
volves the entire area from the vertebral column to the sternum. 
Moreover, it is attended by the three painful points of Valleix, 
pressure upon which accentuates the pain. These points corre- 
spond to the points of emergence of the cutaneous filaments of the 
intercostal nerves. One of these points is situated in the posterior 
extremity of the intercostal space close to the vertebral column ; 
another is situated upon the lateral thoracic wall equi-distant 
from the vertebral column and the sternum; while the third is 
situated upon the anterior thoracic surface adjacent to the lateral 
sternal border. In addition to the presence of these painful 
points, the pain of intercostal neuralgia is paroxysmal in its 
character. 

Neuralgia of the phrenic nerve causes characteristic tender- 
ness of the thorax. In this condition pain is elicited upon the 
exertion of pressure upon the antero-lateral thoracic wall at the 
insertions of the digitations of the diaphragm into the seventh, 
eighth, ninth, and tenth ribs; upon the insertion of the muscle 
to the twelfth rib adjacent to the vertebral column; and upon 
the spinous processes of the third and fourth cervical vertebrae, 
which correspond to the origin of the cervical plexus. While 
neuralgia of this nerve occasionally develops without apparent 



PALPATION OF RESPIRATORY ORGANS 107 

cause, in many instances the underlying factor is a diaphragmatic 
pleurisy or a pericardial effusion. 

The pain of ]3leurodynia is most frequently observed upon the 
left side of the thorax, involving usually the intercostal muscles, 
and with less frequency the pectoralis major and the serratus 
magnus. Pressure exerted with the finger-tips, movements of 
the thoracic wall during respiration, and bending and turning 
of the trunk intensify the pain. The distribution of the pain is 
more diffuse than is the case with intercostal neuralgia, and the 
pain is constant and not paroxysmal as is the case with neuralgia 
of the intercostal nerves. When pleurodynia involves the pec- 
toralis major muscle the pain is greatly aggravated when the 
examiner compresses the body of the muscle between the fingers. 

In periostitis or caries of a rib, the tenderness is limited to the 
rib in question, and usually to a single portion of the rib, while 
compression of the adjacent intercostal spaces is almost devoid 
of pain. Occasionally there is local bulging and discoloration of 
the integument over the site of the lesion. Localized pain upon 
pressure upon a rib is frequently encountered as a result of frac- 
ture of a rib. 

Local tenderness due to peripleuritic abscess is commonly at- 
tended by a local bulging of the thoracic wall, and in the later 
stages of the condition, when perforation of the chest wall is 
imminent, there is local bulging and discoloration of the integu- 
ment. 

THE INTERCOSTAL SPACES 

Li addition to the elicitation of local tenderness, palpation of 
the interspaces is employed in the estimation of their relative 
width in cases of pleurisy with effusion, chronic ulcerative phthi- 
sis, and in unilateral and local deformities of the thorax due to 
pulmonary fibrosis or extensive bronchiectasis. In the presence 
of pleurisy with effusion, the consolidations of lobar pneumonia 
and phthisis, and in cases of excessive pleural thickening, as well 
as in fully developed cases of hypertrophic emiDhysema, finger- 
tip palpation of the intercostal spaces yields a sensation of in- 
creased resistance. 

THE RIBS AND STERNUM 

In addition to the elicitation of tenderness in the presence of 
inflammation and caries of the ribs, palpation of these structures 



108 PHYSICAL DIAGNOSIS 

in syphilitic subjects occasionally reveals the presence of gum- 
matous nodules. In rickets the rachitic rosary is often present 
in the form of a series of palpable or even visible nodes occurring 
in series upon either side of the thorax at the junction of the ribs 
with their costal cartilages. 

Palpation of the sternum is serviceable in the detection of minor 
variations in the prominence of the angulus Ludovici, and also 
frequently reveals the presence of caries of this bone. Painful 
enlargement of the sternoclavicular articulation is more common 
in connection with gonorrheal rheumatism than in any other 
disease. Prominence of the superior portion of the sternal region, 
attended by pain of a dull, boring character, is significant of 
aneurysm of the aortic arch. 

LOCAL PULSATION 

Palpation is serviceable in confirming the findings of inspection 
as to pulsation of various regions of the thoracic surface ; for de- 
tecting minor degrees of thoracic pulsation which may have 
escaped detection during inspection; and to gauge the force or 
lifting power of a thoracic pulsation. 

In empyema, when this involves the left pleural cavity, the im- 
pact of the heart is communicated to the fluid during cardiac 
systole, creating thus a systolic pulsation in the lower left antero- 
lateral thoracic region. Frantzel has described a similar systolic 
pulsation which was transmitted to a purely serous pleural ef- 
fusion, and Eichhorst has encountered in the child similar pulsa- 
tions in serous effusions of the right pleura, in this instance local- 
ized to the right lower anterolateral thoracic region. Similarly, 
when the lingula of the left lung which overlies the heart in the 
left mammary region becomes the seat of dense consolidation in 
pneumonia or is invaded by dense carcinomatous infiltration, 
there is generated a systolic pulsation or pulsion of this region 
of the thoracic wall with each ventricular systole. 

In the presence of empyema necessitatis of the left antero- 
lateral thoracic wall, there is produced, just as in the case of 
aortic aneurysm, a systolic pulsation which is expansile in char- 
acter, occurring in all directions. This expansile pulsation of the 
protrusion may be determined with ease by applying the fingers 
widely separated to the various walls of the sac simultaneously, 
whereupon the fingers will be moved apart with each systole of 
the heart which is transmitted to the contained fluid. 



PALPATION OF RESPIRATORY ORGANS 109 

In the differentiation of snch a pulsating empyema necessitatis 
from aneurysm Miiller calls attention to the fact that empyema is 
situated in the loAver left antero-lateral region of the thorax, 
whereas aneurysm is localized in the upper and right portion of 
the thorax; that in the case of empyema, progressive, gentle pres- 
sure exerted upon the protrusion will cause its reduction by evac- 
uation of the purulent contents into the pleural cavity through 
the fistulous communication between the pus sac and this cavity ; 
that in empyema the zone of dullness extends well beyond the 
limits of the tumor; and that in empyema no systolic bruit is 
audible as is the case with aneurysm. 

A peripleuritic abscess overlying the ventricle of the heart is 
attended by a systolic pulsation in this area ; but in this instance, 
as the purulent accumulation is enclosed in a cavity with rela- 
tively dense walls, the pulsation is manifested as a simple raising 
and recession and is not expansile. 

A palpable pulsation occurring over a relatively broad area 
upon the left side of the posterior wall of the thorax below the 
angle of the scapula, is occasionally noted in connection with an 
extensive tuberculous excavation of the left lung, when this 
cavity is filled with fluid, to which the impact of the heart is 
transmitted during systole. 

FLUCTUATION 

Fluctuation is not ordinarily demonstrable in connection with 
disease of the thoracic viscera, on account of the rigidity of the 
thoracic wall. Pleural effusion, if it is very extensive and is 
attended by marked widening of the intercostal spaces, occasion- 
ally yields fluctuation upon tapping the thoracic w^all while the 
flngers of the opposite hand are pressed firmly into the inter- 
costal space. This fluctuation is more frequently demonstrable 
in the case of children with empyema. 

In cases of empyema necessitatis, in which the accumulation of 
purulent material is extensive and rupture is imminent, pitting 
upon pressure is readily obtained, and fluctuation is not infre- 
quent. It is elicited by placing the palm of the palpating hand 
over the protruding area and rather forcibly striking the oppos- 
site side of the thorax with the free hand, a procedure which is 
not devoid of danger in all cases. In most cases of empyema 
necessitatis the local bulging may be made to disappear by pro- 
gressive pressure exerted upon the tumor by the palm of the 



110 PHYSICAL DIAGNOSIS 

hand. Upon removal of the pressure the tumor resumes its for- 
mer dimensions. Not infrequently the size of the protrusion 
caused by empyema necessitatis is variable, depending upon the 
depth of the respirations. Fluctuation is occasionally demon- 
strable in the presence of abscess of the pectoral wall, whether 
due to disease of the . thoracic musculature, the ribs, or caries 
of the bodies of the dorsal vertebra. Aneurysm of the aortic 
arch, with erosion of the sternum, presents an expansile, fluctuat- 
ing tumor, above the base of the heart. 



CHAPTER IV 
PERCUSSION 

Object and Technic. — Percussion was first applied to the ex- 
ploration of pathologic states of the respiratory organs by 
Anenbrugger of Vienna in 1761. However, the value of percus- 
sion was not fully appreciated until the year 1808, when the 
French physician Corvisart, physician to Napoleon I., revived the 
subject and further elaborated the technic of percussion. During 
the. same epoch Piorry of France introduced topographical per- 
cussion of the thoracic viscera, and Skoda of Vienna published 
his studies upon the probable genesis of hyperresonance and 
tympany in connection with pulmonary relaxation and compres- 
sion. The technic of percussion and the attributes and mode of 
production of the various percussion findings were further eluci- 
dated by the epoch-making researches of such investigators as 
Wintrich, Traube, Biermer, Gerhardt, and Weil. Indeed, so 
thorough were the studies undertaken by these latter investi- 
gators, that modern investigation has accomplished little in the 
way of additions to the physical laws which were enunciated by 
these authors in relation to the generation of the various char- 
acteristics of the percussion sounds. 

Percussion is employed in the study of disease of the respira- 
tory organs for the purpose of eliciting sounds which are normal 
to the pulmonary parenchyma and sounds w^hich only arise in 
the presence of diseased states of these organs ; to determine the 
situation of the borders of the intrathoracic organs ; and also to 
note the degree of resistance offered to the percussion stroke by 
the tissues under examination. 

Percussion, as commonly practiced, consists in striking the 
surface of the area under examination with a view primarily to 
eliciting sound, and secondarily for the determination of the 
degree of resistance offered to the percussion blow. During this 
maneuver the percussion blow may be directed with the finger or 
with a specially devised percussion hammer, and either directly 
upon the part under examination, or upon an intervening medium, 
usually a finger of the opposite hand of the examiner, or in other 
instances plates of metal, glass, ivory, or hard rubber. The in- 
Ill 



112 PHYSICAL DIAGNOSIS 

strument Avitli which the blow is struck, finger or hammer, is 
termed the plexor; the intervening medium, finger or plate, is 
termed the pleximeter. When an intervening medium or plexim- 
eter is employed, the percussion is termed mediate percussion; 
whereas when no such intervening instrument is present, but the 
blow is delivered directly upon the part which is under examina- 
tion, the percussion is termed immediate percussion. 

Immediate Percussion. — In the practice of immediate or direct 
percussion the pleximeter is dispensed with and the blow is struck 
directly upon the chest wall. The finger-tips or the palm of the 
hand may be employed, the former in the percussion of the 
clavicles to determine the presence of consolidation of the apices 
of the lungs, and the latter in lightly slapping the two halves 
of the thorax in the effort to demonstrate the presence of dullness 
over a relatively large area, usually at the bases posteriorly. 




Fig. 41. — Percussion Iiamirer. 




Fig. 42. — Hard rubber pleximeter. 

Mediate Percussion. — This, the most frequently employed mode 
of percussion, is practiced by two methods; namely, by instru- 
mental percussion, and by -finger percussion. Each method has its 
inherent advantages ; but it is advisable for the student to perfect 
himself in one method and to discard the other. 

In instrumental percussion the blow is directed upon a plexim- 
eter of glass, ivory, rubber, or metal by means of a special per- 
cussion hammer. It is essential that the pleximeter shall be 
sufficiently narrow to fit into the intercostal spaces without over- 
lying the adjacent ribs, and it is necessary that the plexor be 
equipped with a head of soft rubber in order to avoid the produc- 
tion of adventitious sound during the delivery of the percussion 
blow. 

In the practice of finger percussion a finger of the left hand of 
the examiner is applied firmly and evenly with the palmar aspect 



PERCUSSION OF RESPIRATORY ORGANS 



113 



down upon the area under examination while the blow is delivered 
by one or more fingers of the right hand, the plexor finger or fingers 
being flexed as nearly as possible at a right angle. The stroke 
should preferably be directed upon the base of the nail or upon 
the second phalanx of the middle finger of the pleximeter hand. 
To obtain satisfactory data by finger percussion it is essential 
that the pleximeter finger be applied firmly and evenly upon the 
part; that the percussion stroke be delivered quickly and in a 
vertical direction; that the plexor finger be raised immediately 
and not be permitted to remain in contact with the pleximeter; 




Fig. 43. — Immediate percussion of 
clavicle. 



Fig. 44.- — Immediate percussion of 
pulmonary bases. 



that the percussion blow be delivered entirely by a wrist movement, 
the forearm not participating; and that the successive blows be 
delivered with uniform intensity. 

Finger percussion is preferable to instrumental percussion for 
the reason that the pleximeter finger becomes a sensitive palpating 
medium, appreciating minor variations in the degree of resistance 
which the chest wall offers to the percussion stroke. Moreover, the 
finger may be more firmly applied to the area under investigation, 
excluding the possible intervention of air between chest wall and 
pleximeter. 



114 



PHYSICAL DIAGNOSIS 



In the practice of mediate percussion only*a few strokes should 
be employed in a given region. As much information is to be 
obtained by four or five strokes properly directed as by a greater 
number, which tend to impair the nicety of the auditory apprecia- 
tion of the tones which are elicited. In comparing the quality of 




Fig. 45. — Percussion of pulmonary apices. 



Fig. 46. — Percussion of lateral thoracic 
region. 




Fig. 47. — Percvission of posterior thorax. 



the sound elicited upon the two sides of the chest, exactly corre- 
sponding points should be selected upon either side ; and the per- 
cussion blows should be delivered with uniform force in each 
instance. 

Percussion is practiced with most satisfactory results with the 



PERCUSSION OF RESPIRATORY ORGANS 115^ 

patient in the sitting or standing postnre. During percussion of 
the anterior surface of the thorax, as well as in percussion of the 
supraclavicular regions, the hands should hang naturally at the 
sides, the head should be held symmetrically in the median plane 
of the body, and the entire attitude of the patient should be natural 
and unconstrained. In percussion of the supraclavicular and 
infraclavicular regions, the examiner, assuming a position at the 
side of the patient should apply the pleximeter fingers firmly and 
evenly to the integument in these regions, the index and middle 
fingers occupying the infraclavicular region and the ring finger 
occupying the supraclavicular region. During percussion of the 
lateral regions of the thorax a good exposure is obtained by direct- 
ing the patient to clasp the hands behind the head, the arms mean- 
while being drawn backward. In percussion of the posterior 
thoracic wall the patient should bend the trunk forward, meanwhile 
crossing the arms upon the chest, and approximating the elbows. 
In this attitude the scapula are widely separated and are closely 
applied to the bony thorax. When it is necessary to practice per- 
cussion with the patient in the recumbent posture the examiner 
should bear in mind the adventitious impairment of resonance in 
the dependent portion of the thorax ; and the patient must be 
turned a sufficient number of times to insure the percussion of all 
regions of the thorax in the most favorable posture obtainable. 

PALPATORY PERCUSSION 

In the practice of this method of percussion the primary object 
is the determination of the degree of resistance afforded by the 
underlying structures rather than the production of sound. Pal- 
patory percussion is employed in both direct and indirect 
methods. In the former the chest wall is struck with the pads 
of the finger-tips with a pushing movement, the sensitive finger- 
tips noting the degree of resistance to the blow. Indirect or 
mediate palpatory percussion is practiced by striking the plexi- 
meter finger with a tardy, pushing movement rather than with 
the sharp, quick stroke of routine percussion, and allowing the 
plexor to remain for an instant upon the pleximeter. 

Palpatory percussion is of service in determining the presence 
of fiuid in the pleural cavity and in outlining the borders of a 
hypertrophied heart or a large pericardial effusion by the grada- 
tions which are encountered in the resistance to the percussion 
blow. 



116 



PHYSICAL DIAGNOSIS 



AUSCULTATORY PERCUSSION 

This method of percussion, which combines auscultation with 
mediate or immediate percussion, is employed for the purpose 
of outlining the borders of solid organs, consolidations, neo- 
plasms, and collections of fluid. In the practice of auscultatory 
percussion the chest-piece of the stethoscope is applied over the 
organ, consolidation, or structure which is to be outlined, and is 
retained in position by the patient or an assistant while the 
examiner, after first percussing near the bell of the instrument 
and fixing in his mind the quality of the note which is elicited, 
proceeds to percuss toward the instrument from the several direc- 
tions upon the surface of the thorax. In the performance of this 




Fig. 48. — Auscultatory percussion. 

maneuver mediate percussion may be employed or direct palpatory 
percussion, or immediate percussion in the form of rapid finger 
flicking. Instead of employing percussion, the same result is 
obtained if the vibrating tuning-fork is drawn over the integu- 
ment of the thorax toward the bell of the instrument; or, in the 
absence of this instrument, by drawing the rubber eraser of an 
ordinary pencil over the skin. 

In auscultatory percussion of solid structures which are 
covered by pulmonary tissue the note is observed to undergo two 
successive alterations : a primary impairment of resonance, which 
is followed secondarily by frank dullness or flatness. The several 
points at which the percussion note is observed to change may 
be marked upon the skin with a dermographic pencil; and, when 



PERCUSSION OF RESPIRATORY ORGANS 117 

connected by a line drawn through each of them, will indicate 
the borders of the organ or structure under examination. Most 
frequently employed in outlining the areas of relative and abso- 
lute cardiac dullness, auscultatory percussion is also useful in 
differentiating by tonal variations between the dullness of the 
liver and that due to pneumonic consolidation of the right base 
or pleural effusion of the right side. Similarly, it is an invaluable 
aid in differentiating consolidations of the left lung from the dull- 
ness of the heart. 

RESPIRATORY PERCUSSION 

This mode of percussion consists in percussion of the two sides 
of the thorax during quiet respiration and again during forced 
inspiration with the object of determining minor variations in 
the pulmonary resonance upon the two sides of the thorax. The 
method is particularly useful in the detection of minor degrees 
of consolidation. In incipient phthisis upon consecutive per- 
cussion during quiet and during forced inspiration, the dullness 
upon the consolidated side remains unaltered, while the sound 
side exhibits an increase of resonance. 

SUPERFICIAL AND DEEP PERCUSSION 

The terms superficial and deep as applied to percussion have 
special reference to the force of the percussion blow, and each 
method has its indications in the examination of the thoracic 
viscera. In practicing superficial percussion the thorax is tapped 
quickly and lightly, whereas in deep percussion the blow is de- 
livered with sufficient force to set up vibrations in the deeper 
structures. In the examination of persons with thin chest walls 
as well as in the examination of children, superficial percussion 
is to be employed. It is also to be preferred in the delimitation 
of consolidations which are situated immediately beneath the 
chest wall, in order to obviate the establishment of confusing 
vibrations in the deeper structures. 

In the examination of patients with thick chest walls, on the 
contrary, and in the elicitation of dullness of deep consolidations 
which are covered by normal pulmonary tissue, forcible or deep 
percussion is to be employed. This method of examination is 
useful in eliciting the dullness of central pneumonia, deeply 
situated aortic aneurysm, and in estimating the upper limit of 
hepatic dullness. 



118 PHYSICAL DIAGNOSIS 

ATTRIBUTES OF THE PERCUSSION SOUND 

The sound which is elicited upon percussion of the thorax 
possesses certain inherent attributes or properties ; namely, 
quality, pitch, intensity or volume, and duration. 

Quality. — Quality is the property or attribute by which a given 
sound is distinguished from a sound of different origin. It is by 
the quality of the sounds that the sound which is produced upon 
striking a piece of iron is distinguished from that which is pro- 
duced upon striking a piece of wood, and by which the sound 
which is produced upon percussing over the normal lung is 
differentiated from that which is elicited upon percussing over 
a solid organ. It is their quality which gives to the various 
sounds which are elicited upon percussion their individuality 
and much of their localizing value. 

Pitch. — The pitch of a sound is determined by the rapidity of 
the vibrations by which the sound is produced. When the surface 
of the thorax overlying the lung is percussed, the air content of 
the innumerable pulmonary alveoli is thrown into vibration. 
Pitch may be high or low, depending as it does upon the rapidity 
of these vibrations, rapid vibrations producing a note of high 
pitch, while slow vibrations produce one of low pitch. The rate 
of the vibrations is in turn influenced by the size of the cavity 
containing the air and by the force of the percussing blow, being 
more rapid in small cavities and with forcible percussion blows. 

Intensity. — Intensity, or volume, has reference to the loudness 
of the sound, this in turn depending upon the amplitude of the 
vibrations which are generated, the force of the percussion blow, 
the thickness of the chest wall, and the amount of air in the area 
under examination. With heavy percussion over an area of lung 
containing an excess of air and with a thin chest wall, an intense 
sound is produced ; while a similar stroke over a region containing 
little air, overlaid by thick chest walls, produces a sound of minor 
intensity. 

Duration. — The duration of length of the percussion sound pos- 
sesses less of diagnostic significance than do the other attributes. 
In general, it may be stated that the clearer the note and the 
higher the pitch, the shorter the duration; the duller the note and 
the lower the pitch, the longer the duration. 

DEGREE OF RESISTANCE 

Aside from eliciting sound, percussion is employed to determine 
the degree of resistance as appreciated by the pleximeter. In 



PERCUSSION OF RESPIRATORY ORGANS 119 

many instances the degree of resistance encountered affords as 
valuable information as does the sound which is elicited ; and in 
cases where for any reason the sounds produced are not typical, 
it may be the sole guide of the examiner. Increased resistance 
to the percussion blow as appreciated by the pleximeter indicates 
a decrease in the air content of the part and a corresponding 
increase in solid structure or the presence of fluid. A high 
pitched note with well marked sense of resistance indicates that 
the air content is small while the proportion of solid material is 
correspondingly in excess of the normal amount. 

NORMAL PERCUSSION SOUNDS 
Pulmonary Resonance 

The sound which is elicited upon percussion of the surface 
of the thorax which overlies normal crepitant pulmonary tissue 
is termed pulmonary resonance, or normal vesicular resonance. 
When the thoracic surface is percussed, the aerial content of the 
pulmonary infundibula and alveoli which are situated within the 
range of the shock of the percussion blow is caused to vibrate, with 
the consequent production of sound. The quality of this sound is 
distinctive, and is only afforded by percussion of normal pulmonary 
tissue containing its normal quota of air separated by innumerable 
interalveolar septa. The intensity and pitch of the sound depend 
upon the amplitude and rate of the vibrations which are generated 
in the aerial content of the closed spaces, by the distance of these 
air-containing spaces from the thoracic surface, and by the thick- 
ness of the chest walls. With strong percussion, vibrations of 
greater amplitude are generated with the production of a more 
intense sound than that which is produced by feeble percussion. 
Similarly percussion of the thorax in the infraclavicular and axil- 
lary regions, situations in which the pulmonary tissue is closely 
apposed to the thoracic walls is attended by a more intense sound 
than is percussion of the region of the shoulder girdle where the 
lung is separated by voluminous musculature and bony structures 
from the surface of the thorax. Similarly in the thin thorax of the 
female subject and the child the resonant note of percussion of the 
normal lung possesses greater intensity than in the corresponding 
region in the normal adult male subject. 

The normal thorax presents certain regional variations in pul- 
monary resonance with which it is essential that the examiner 
be familiar. Pulmonary resonance of maximum purity is obtained 



120 PHYSICAL DIAGNOSIS 

upon percussion of the first two intercostal spaces in the infra- 
clavicular region for the reason, as Seitz has shown, of the greater 
width of the intercostal spaces, and the relative thinness of the 
thoracic wall in this region. In these interspaces, however, the 
resonance exhibits minor variations in its intensity. It attains 
its maximum intensity in the midclavicular line, from which point 
it diminishes in intensity as one percusses outward toward the 
shoulder where the great pectoral muscle becomes more voluminous, 
and inward toward the sternum, in which situation the anterior 
border of the lung becomes progressively thinner, and presents a 
less voluminous pulmonary parenchyma in the sphere of the shock 
of the percussion blow. In right-handed subjects the resonance is 
usually slightly less intense upon the right side of the thorax in the 
first two interspaces, owing to the more excessive development of 
the pectoral muscles upon this side. It is, moreover, frequently 
noted that the resonance which is elicited in the first intercostal 
space is slightly less intense than that which is produced upon 
percussion of the second interspace, a fact which is explained by 
the fact that the first intercostal space is more deeply situated 
than is the second owing to the backward course of the first rib be- 
neath the clavicle, and by the fact that in the act of mediate per- 
cussion the pleximeter is forced in the majority of cases to rest 
partially upon these bones. 

During percussion of the first two intercostal spaces, careful 
comparison of the intensity of the resonance should be made upon 
the two sides of the thorax. In percussion of the regions of the 
anterior thoracic surface below the second interspace such compari- 
son is useless on account of the influence which the projection of 
the heart toward the left has upon the intensity of the two sounds. 

In the third and fourth intercostal spaces the pulmonary res- 
onance is less pure than in the first two spaces, owing to the ex- 
tensive distribution of the great pectoral muscle in these regions, 
to the thickness of the panniculus adiposus of the mammary gland, 
and, upon the left side, the projection of the heart to the left of 
the sternal border. Seitz holds that the more pronounced narrow- 
ing of the intercostal spaces as one descends upon the anterior 
thoracic wall plays an important part in the progressive enfeeble- 
ment of pulmonary resonance which is encountered. 

In the fifth intercostal spaces pulmonary resonance is variable 
upon the two sides of the thorax. Upon the left side of the thorax 
in the male subject the intensity of the resonance is moderately 
impaired by the presence of the mammary gland, and markedly 



PERCUSSION OF RESPIRATORY ORGANS 121 

impaired by the same giancl in the female subject. Moreover, 
internal to the midclavicular line upon this side of the thorax in the 
area of relative cardiac dullness, corresponding to the region in 
which the heart is invested by the anterior pulmonary border, 
which becomes progressively less voluminous, there is marked im- 
pairment of pulmonary resonance. Similarly, upon the right side 
of the thorax in the fifth interspace the area of relative hepatic 
dullness is encountered in which the upper diaphragmatic surface 
is clothed by the thin lower border of the lung, yielding a diminu- 
tion of resonance which is soon to terminate in frank flatness when 
the area is attained in which the liver is directly apposed to the 
anterior thoracic wall. In the right fifth intercostal space the 
areas of relative cardiac and relative hepatic dullness meet at 
almost a right angle, forming an angle of pulmonary resonance 
immediately to the right of the sternum in this interspace, Eltstein's 
cardiohepatic angle. 

In the sixth right intercostal space pulmonary resonance exhibits 
an abrupt transition into flatness, indicating in this situation the 
superior limit of the area of hepatic flatness, in which the liver is 
in immediate apposition, beneath the diaphragm with the anterior 
thoracic wall. 

In all regions of the thorax percussion over the ribs and bony 
structures yields pulmonary resonance of less purity than that 
which is obtained upon percussion of the intercostal spaces. In- 
deed, as one percusses inward in the superior intercostal spaces 
toward the sternum, as this bone is encountered, the osteal reso- 
nance afforded by percussion of this bone blends with the pulmonary 
resonance of the intercostal spaces. 

In the supraclavicular regions pulmonary resonance is encount- 
ered which becomes progressively^ more intense as one percusses 
inward toward the median line, to finally give place in this location 
to the tj^mpany of the trachea. The progressive increase in intens- 
ity of pulmonary resonance under these circumstances should be in 
all cases attributed to its real cause, the proximity of the trachea 
to the pulmonary apices in the median line of the body. Of quite 
different significance is hyperresonance encountered in these 
regions, when this is encountered throughout the region and ex- 
tends well outward toward the distal extremity of the clavicle. 

Percussion of the clavicle yields resonance of impaired intensity, 
which contrasts markedly with the purity of the pulmonary reso- 
nance in the infraclavicular region. Excessive curvino^ of this bone 



122 PHYSICAL DIAGNOSIS 

■ * 

further impairs the purity of the resonance as do also irregularities 
due to former fractures or osseous disease. 

Percussion of the sternal region, overlying the sternum and 
ensiform cartilage, yields three distinct variations in pulmonary 
resonance. Aside from the influence which the osteal resonance of 
the bone exerts upon the pulmonary resonance, there are distinct 
variations in the quality and intensity of the pulmonary resonance 
as a result of the influence upon the latter of the anatomic struc- 
tures with which the sternum is in relation in different portions 
of its distribution. Percussion of the manubrium sterni and the 
portion of the gladiolus above the level of the fourth costal carti- 
lage yields upon forcible percussion resonance blended with the 
tympany of the subjacent trachea and primary bronchi. Below 
this level percussion of the gladiolus yields rather marked impair- 
ment of resonance, corresponding to the area of relative cardiac 
dullness in which the heart is covered by the thin borders 
of the lungs. Percussion of the ensiform cartilage yields frank 
dullness or flatness, on account of its apposition with the left lobe 
of the liver. However, in the presence of extreme distention of the 
stomach with gas, this flatness may be replaced with gastric tym- 
pany, which has nothing in common with the quality of pulmonary 
resonance. 

Upon the lateral walls of the thorax pulmonary resonance is 
somewhat less intense than upon the anterior wall; but it is de- 
cidedly more intense than is the case upon the posterior wall of 
the thorax. In this regard, the three aspects of the thorax present 
the same relative variations in regard to the intensity of pulmonary 
resonance as was observed in the same regions in the study of vocal 
fremitus. 

However, whereas in the case of vocal fremitus the tactile vibra- 
tions are observed with slightly exaggerated intensity upon the 
right lateral wall of the thorax, in the case of pulmonary resonance 
the reverse obtains ; pulmonary resonance is slightly diminished 
upon the right lateral thorax, a diminution which is caused by the 
same factors which make for increased vocal fremitus in this area. 

In the axillary region pulmonary resonance is slightly less 
intense than in the inf raaxillary region ; but in the upper axillary 
region the note is slightly tympanitic on account of the closer prox- 
imity to the chest wall in this region of the larger bronchi. Upon 
percussion of the lateral thoracic wall the resonance is observed 
to augment in intensity as one descends until the seventh inter- 
costal space is reached. At this level upon the right side of the 



PERCUSSION OF RESPIRATORY ORGANS 123 

thorax pulmonary resonance is impaired by the advent of the area 
of relative hepatic dullness ; while at the same level upon the left 
side of the thorax, it is replaced by the tympanitic sound gener- 
ated in the stomach and colon. 

In every portion of the posterior surface of the thorax pulmonary 
resonance is less intense than upon the anterior and lateral regions 
of the thorax. Upon the posterior thoracic wall resonance of great- 
est purity is obtained upon percussion of the pulmonary bases in 
the infrascapular region. Next in order of purity comes the res- 
onance in the inferior half of the interscapular region, and this is 
followed by the superior half of the same region. In the supra- 
scapular and scapular regions, overlying the bony scapulae with 
their thick investment of musculature, pulmonary resonance is less 
intense than in any other portion of the posterior thoracic surface. 
In this region the minimum intensity is encountered along the 
course of the spine of the scapula. 

The Normal Limits of Pulmonary Resonance. — The normal 
limits of pulmonary resonance correspond accurately to the 
anatomical site of the borders of the lungs. The superior limit 
extends into the base of the neck from one to one and one-half 
inches above the clavicles, extending a short distance higher over 
the right than over the left apex. Anteriorly the limits of reso- 
nance lie behind the sternum in the upper portion of the thorax, 
the osteal resonance of this bone interfering greatly in the delimita- 
tion of the anterior pulmonary borders in this region. At the level 
of the fourth intercostal space, however, the anterior limit of 
resonance is displaced to the left by the interposition of the heart 
between the left lung and the chest wall, in the areas of relative and 
absolute cardiac dullness. The inferior limits of normal pulmonary 
resonance are encountered at the level of the sixth rib in the mid- 
clavicular line, the eighth rib in the midaxillary line, and the tenth 
rib in the scapular line. 

Variations in the Limits of Pulmonary Resonance. — In broncho- 
pulmonary disease any lesion which increases the expansion of the 
lung in any direction results clinically in a corresponding increase 
in the area of pulmonary resonance ; and any lesion which de- 
creases the extent of the lung in any direction produces a corre- 
sponding limitation of the resonance to the extent of the lesion. 
It follows that in disease of the lung or pleura there may be a 
general increase or decrease of resonance at all of the pulmonary 
borders ; that the variation may involve two corresponding bor- 



124 



PHYSICAL DIAGNOSIS 



ders; or that only a single area of the lung may present an 
abnormal variation in the extent of pulmonary resonance. 

A general increase of pulmonary resonance in all directions, all 
of the borders of the lungs occupying a position beyond their 
normal limits, is characteristic of hypertrophic emphysema and is 
noted during the paroxysm of bronchial asthma. A similar general 
increase is frequently noted in dyspneic patients with uncompen- 
sated heart disease, and occasionally in subjects of chronic bron- 
chitis. 

A general decrease of pulmonary resonance, due to general re- 
traction of the pulmonary borders, occurs with atrophic emphy- 




A. B. 

Fig. 49. — lyimitation of pulmonary resonance at apices. A. Anterior view. B. Posterior 



sema, in which the lungs are symmetricall}^ shrunken and atrophic. 

Extension of resonance at the apices occurs in connection with 
the paroxysms of bronchial asthma and pertussis as a result of the 
acute vesicular emphysema which attends these attacks. When 
hypertrophic emphysema involves the apices extensively, there is 
extension of the limits of resonance in the supraclavicular regions. 

Decreased resonance at the apices, associated with dullness of the 
percussion note and depression of the supraclavicular fossae, is a 
valuable sign of chronic ulcerative phthisis. Retraction of the 



PERCUSSION OF RESPIRATORY ORGANS 125 

limit of resonance in this direction also occurs with fibroid phthisis, 
apical pneumonia, pulmonary collapse from bronchial obstruction, 
and as a result of traction of adhesions in chronic adhesive pleurisy. 
The apical limitation of resonance in phthisis is commonly bi- 
lateral, whereas that of apical pneumonia and chronic adhesive 
pleurisy commonly involves one apex. 

Extension of resonance of the anterior borders of the lungs so 
that they encroach upon or obscure the area of cardiac dullness 
occurs in established hypertrophic emphysema. During the tran- 
sient acute vesicular emphysema of the paroxysm of bronchial 
asthma and of pertussis the anterior border of the left lung en- 
croaches upon the area of cardiac dullness. 

Decreased resonance of the anterior border of one or both lungs 
is indicative of fibroid retraction of the lung in chronic interstitial 
pneumonia or fibroid phthisis or of displacement of the pulmonary 
border by a hypertrophied heart or by pericardial or pleural 
effusion. In the case of fibroid retraction of the left lung the 
cardiac impulse is diffuse, occupying a wide area in the third, 
fourth, and fifth interspaces ; whereas in the presence of pleural or 
pericardial effusion the impulse is displaced or is invisible. 

Increased resonance of the lower border of the lungs is part and 
parcel of the general extension of resonance accompanying hyper- 
trophic emphysema or bronchial asthma. It may also occur with 
fibrinous bronchitis and uncompensated heart disease. 

Decreased resonance of the lower borders of one or both lungs 
points to fibroid retraction of the lung due to chronic interstitial 
pneumonia or fibroid phthisis ; or to elevation of the diaphragm due 
to paralysis of that muscle or to the subphrenic pressure of ascites, 
abdominal tumor, hepatic, or splenic enlargement. In atelectasis 
and in pleurisy with effusion the lower border of the lung is like- 
wise elevated with diminution in the area of pulmonary resonance 
in this direction. 

THE RESPIRATORY EXCURSION OF THE LUNG 

In estimating the respiratory excursion of the lungs, the lower 
limit of pulmonary resonance should be defined by percussion in 
the midclavicular, midaxillary, and scapular lines during quiet 
and during forced inspiration, and the difference noted. Usually 
measuring approximately one inch, the respiratory excursion is 
very much reduced in subjects of hypertrophic emphysema and 
during asthmatic attacks, as well as in cases of limited dia- 



126 PHYSICAL DIAGNOSIS 

phragmatic excursion occurring as a result of increased subphrenic 
pressure or painful thoracic affections. 

ABNORMAL PERCUSSION SOUNDS 

Impaired Resonance. — The percussion note exhibits slight im- 
pairment of the purity of vesicular resonance, not amounting to 
dullness, which is the next gradation, when there is only a moder- 
ate increase in the solid over the normal crepitant structure of 
the lung. Impaired resonance is elicited particularly in the 




Fig. 50-^. — Areas of dullness in apical pul- Fig. 50-B. — Areas of dullness in apical pul- 
monary tuberculosis. monary tuberculosis. 

early stages of phthisis at the apices of the lungs. Impairment 
of resonance is also a sign of moderate pleural thickening and 
incipient consolidation from pneumonia or other cause. It is 
the first step toward dullness, but is not so pronounced in its 
change of quality. 

The note which is elicited upon percussion over airless struc- 
tures which are separated from the chest wall by the intervention 
of normally crepitant lung is termed relative dullness. This note 
is elicited in percussion of the areas of relative cardiac and 
relative hepatic dullness, in which these organs are overlapped by 
the borders of the luno^s. 



PERCUSSION OF RESPIRATORY ORGANS 



127 




Fig. 51. — Physical causes of change in percussion note. 1-2, dullness upon percussion; 
3, deep dullness masked by intervening lung. 



128 



PHYSICAL DIAGNOSIS 



Dullness. — As in the case of impaired resonance, dullness indi- 
cates a decrease in the air-content of the part and a corresponding 
increase in the solid elements in the area under examination ; but 
the note is more materially altered than it is in impairment of 




Fig. 



52-A. — Area of dullness 
pleural effusion. 



in moderate Fig. S2-B.- 



-Area of dullness in moderate 
pleural effusion. 




Fig. 53-^. — Percussion findings in sero- 
fibrinous pleurisy with effusion. 



Fig. S2,-B. — Percussion findings in sero- 
fibrinous pleurisy with effusion. 



PERCUSSION OF RESPIRATORY ORGANS 



129 



resonance. A dull note is elicited upon percussion in the presence 
of the consolidations of pneumonia and phthisis, infiltration of 
the lung with edema and hypostatic congestion, in carcinomatous 
infiltration, in the presence of considerable pleural thickening, in 
the area of a lung which is compressed by a tumor, in atelectasis 
which is extensive in distribution, and in pulmonary syphilis and 
in hemorrhagic infarction of the lung. 

Dullness localized to a special region is encountered in pleurisy 
with effusion, owing to compression or condensation of the medi- 
astinal structures and their deflection toward the side of the thorax 
opposite to the effusion. Thus, in pleurisy with effusion there is fre- 





Fig. 54-^. — Dullness of aortic aneurysm. Fig. 54--B. — Dullness of aortic aneurysm. 

quently a triangular area of paravertebral dullness opposite the side 
of the effusion, at the level of the twelfth dorsal spine, constitut- 
ing Grocco's sign of this disease. 

Dullness which is circumscribed to the left interscapular region 
is noted in connection with aneurysm of the thoracic aorta. Dull- 
ness in this region may, however, signify enlargement of the bron- 
chial glands or mediastinal tumor. Apical dullness, when associ- 
ated with normal pulmonary resonance over other portions of the 
lung, points to incipient phthisis; but similar dulling of the note 
in this region is present in apical pneumonia and in pleural thick- 
ening'. 



130 PHYSICAL DIAGNOSIS 

Flatness. — Flatness, a percussion note which is entirely devoid 
of resonance, is indicative of entire absence of air from the area 
percussed. It is elicited upon percussion over a consolidated 
lobe in fibrinous pneumonia, over a pleural effusion, a tumor of 
the lung or pleura, a greatly hypertrophied heart, a cirrhosed 
lung, hydrothorax, or a pulmonary cavity which is filled with 
fluid. A deeply seated consolidation, which is overlaid by normal 
lung, frequently fails to give dullness or flatness owing to com- 
pensatory emphysema of the intervening lung and requires deep 
percussion to elicit dullness. 

Flatness of one base posteriorly, associated with skodiac res- 
onance of the apex of the corresponding lung, frequently accom- 
panied by Grocco's sign in the opposite paravertebral region, is 
indicative of serofibrinous pleurisy or empyema. Flatness in the 
same area, shifting with change of posture is very suggestive of 
hydropneumothorax. Flatness anteriorly, obscuring the normal 
gastric tympany of Traube's semilunar space, occurs with left- 
sided pleural effusion, while flatness in Ebstein's cardiohepatie 
angle accompanies right-sided effusion. 

Hyperresonance. — Hyperresonance, an increase in normal 
vesicular resonance, is characterized by an abnormal clearness of 
the percussion sound, as a result of an increase of the air content 
of the area which is percussed. Hyperresonance may be bilateral, 
unilateral, or localized to a limited area of the chest. When bi- 
lateral hyperresonance is elicited, it usually indicates hyper- 
trophic emphysema; when unilateral, compensatory emphysema 
is the usual underlying cause; while localized hyperresonance is 
elicited over a small portion of a lung which is the site of vicari- 
ous distention to compensate for an adjacent focus of compres- 
sion, collapse, or consolidation. Such a localized area of hyper- 
resonance is often indicative of a deeply seated patch of consoli- 
dation, which requires deep percussion to indicate its presence. 

TYMPANY 

Tympany represents the acme of hyperresonance, percussion 
of the thorax yielding in this instance a tympanitic or drum-like 
sound. Its prototype in the human economy is produced by 
percussion over the stomach when this viscus is moderately dis- 
tended with gas and by percussion over the larynx and trachea. 
Tympany is encountered upon percussion over pulmonary cavities 
which contain air, whether these possess a patent bronchial 



PERCUSSION OF RESPIRATORY ORGANS 



131 




Fig. 35.— Physical causes of change in percussion note. /, normal vesicular resonance; 
2-3, impaired resonance, or relative dullness; normal vesicular resonance upon super- 
hcial percussion, impaired resonance upon deep percussion; 4, normal vesicular resonance: 
5. dullness; 6, flatness of fluid origin. 



132 PHYSICAL DIAGNOSIS 

■ * 

communication or are closed, and upon percussion of pulmonary 
tissue which is in a state of relaxation or compression. 

The intensity of the tympanitic note depends upon the ampli- 
tude of the vibrations which are generated within the area per- 
cussed, upon the distance of the area in question from the 
thoracic walls, and upon the thickness of these walls. The in- 
tensity of the sound is greater in the case of large superficial 
cavities than in the case of cavities of smaller size owing to the 
greater mass of air Avhich is set in vibration and the readiness 
with which the vibrations are transmitted to the exterior of the 
thorax. 

The pitch of the tympany depends upon the size of the cavity; 
upon the presence or absence of a patent bronchial communica- 
tion; upon the diameter of the bronchial communication when 
such is present ; and upon the tension of the walls of the cavity. 
In interpreting variations in the pitch of the tympanitic sound in 
any case the student should bear in mind the physical principles 
governing the pitch of the tympanitic sound as generated by 
percussion over pulmonary excavations ; namely, that the pitch 
of the tympany is in inverse proportion to the length of the 
column of air which is set in vibration upon percussion of the 
cavity, and in direct proportion to the diameter of the bronchial 
communication, if there be one; that the shorter the air column 
which is set in vibration, or in other words, the smaller the 
dimensions of the cavity, the higher isjhe pitch of the tympany; 
that the greater the diameter of the bronchial communication, 
the higher is the pitch, and the smaller the transverse diameter 
of the bronchial communication, the lower is the pitch; that of 
two closed cavities the tympany will be of higher pitch in the one 
which shall have the lesser vertical diameter, and vice versa; and 
that percussion of a large closed cavity may yield a tympanitic 
note of higher pitch than a smaller cavity which has a bronchial 
communication of small diameter, the lowering of the pitch in the 
latter instance being determined by the narrow orifice of the 
bronchial communication. From this last consideration it follows 
that before basing conclusions as to the probable dimensions of a 
pulmonary cavity upon the pitch of the tympany, it is necessary to 
establish whether the cavity is closed or open by the changes of 
sound of Wintrich and Friedreich, to be described in a subsequent 
paragraph. 

The influence of the length of the air column upon the pitch of 
the tympanitic percussion note is readily demonstrated by percus- 



PERCUSSION OF RESPIRATORY ORGANS 



133 



sing a pleximeter successively above the orifices of glass cylinders 
which are filled with varying quantities of water, or upon percussion 
above the mouth of a glass cylinder while an assistant slowly pours 
water into the cylinder along its walls. Under these circumstances, 
it is observed that as the water mounts in the cylinder and as the 
column of air becomes progressively smaller, the percussion note 
becomes progressively higher in pitch. 

The influence of the diameter of the orifice of the bronchial 
communication upon the pitch of the percussion note can be demon- 
strated in an experimental manner by percussing above glass 




Fig. 56. — Physical basis of pathologic physical signs upon percussion and auscultation 
of the thorax. 

A, cracked-pot sound; B, Biermer's phenomenon; C, pectoriloquy; D, lung-fistula 
sound; /, cracked-pot sound; 2, Wintrich's change of sound; j, Friedreich's change of 
sound; 4, bronchial or amphoric respiration; 5, whispering pectoriloquy. 



cylinders which are covered with pieces of cardboard in which are 
perforations of variable diameter, or by percussing above a single 
cylinder, first with the mouth of the cylinder uncovered, and suc- 
cessively as it is covered with pieces of cardboard with perforations 
of progressively descending diameter. Under these circumstances 
it will be observed that the percussion tympany is of highest pitch 
in the case of the uncovered cylinder, and that its pitch becomes 
progressively lower as the orifice of the cylinder becomes smaller. 
The mechanism of generation of the tympanitic percussion sound 



134 PHYSICAL DIAGNOSIS 

■ * 

and its quality when generated are in very intimate relationship 
the one with the other. Upon percussion of a pulmonary cavity 
with smooth walls vibrations are created in the air of varying 
amplitude. In the case of cavities with smooth walls and with free 
bronchial communication the state of affairs is in some degree 
analogous to that which obtains in the pipes of an organ or other 
wind instrument in which the quality and pitch of the notes depend 
upon variations in the length of the vibrations which are produced. 
Like the pipe of the organ, a pulmonary cavity with smooth walls 
and free bronchial communication acts as a resonator for certain 
of the vibrations which are created in the air content upon percus- 
sion. The quality of the tympany which is elicited depends upon 
the rate of vibration of the fundamental vibrations, which are the 
slowest vibrations which the chamber is capable of responding to, 
and the rapidity of these vibrations is in direct relation to the 
length of the column of air contained in the cavity, or, in other 
words, to the length of the cavity. It is thus that is explained the 
change of sound of Wintrich, which will be discussed in a subse- 
quent paragraph. 

It is essential that a cavity possess smooth walls in order to 
yield a tympanitic sound upon percussion ; and when the walls of 
a cavity become coated with fibrinous exudate or tissue debris, 
the tympanitic character of the sound elicited upon percussion is 
lost. Wintrich found in his experiments that upon percussion 
above the orifice of a cylinder sunk in soft, dry snow that he 
obtained tympany, whereas upon percussion above the ragged 
depression left after removal of the cylinder that tympanism was 
absent. He also demonstrated the absence of tympany upon 
percussing above vessels of leather, felt, and other materials of 
irregular surface. 

A pulmonary cavity must attain certain dimensions in order to 
yield a tympanitic percussion sound. Wintrich places the mini- 
mum diameter at six centimeters; while Skoda failed to obtain 
tympany in cavities approximately the size of the fist. 

While all pulmonary cavities which contain air and possess a 
patent bronchial communication present the physical requirements 
for the production of tympany upon percussion, it frequently 
happens that cavities are too deeply seated in the lung to yield 
tympany upon percussion. It is only when such a cavity is situ- 
ated in the periphery of the lung that tympany is to be elicited, 
and even in these cases cavitation is frequently not detected by the 
experienced examiner. 



PERCUSSION OF RESPIRATORY ORGANS 135 

The tympanitic percussion sound is capable of exhibiting four 
changes of sound under appropriate conditions ; namely, the change 
of sound of Wintrich, the interrupted change of sound of Wintrich, 
the respiratory change of sound of Friedreich, and the change of 
sound of Gerhardt. 

WINTRICH 'S CHANGE OF SOUND 

Wintrich demonstrated that upon percussion of a superficial 
pulmonary cavity with patent bronchial communication the 
tympany is of higher pitch with the patient 's mouth open and of 
lower pitch when the lips are tightly closed during the percussion. 
The accepted physical basis for this change in pitch is, in brief, 
that the buccal cavity, which acts as a resonating chamber for 
the vibrations which are conducted to it from the pulmonary 
cavity by way of the respiratory passages, is tuned for different 
vibrations accordingly as the lips are opened or as they are 
closed; that is to say, that Avitli the lips closed the buccal cavity 
acts as a resonator for the waves of longer amplitude and lower 
rate of vibration, whereas with the lips parted the buccal cavity 
is adapted best to the waves of less extensive amplitude and more 
rapid vibration, which it magnifies to the exclusion of the slower 
vibrations of greater amplitude. 

In the elicitation of the change of sound of Wintrich the patient 
should occupy the seated position, as Baiimler has shown that 
during examination in the dorsal decubitus the root of the tongue 
often tends to close more or less completely the orifice of the 
larynx and to prevent the change of pitch of the percussion sound 
upon opening the lips. Also the change of sound should be elicited 
during the same phase of the respiratory cycle, as the chink of 
the glottis is subject to changes in diameter during the two res- 
piratory acts. Moreover, the act of deglutition, by occluding 
the laryngeal orifice effectually masks the change of sound. 

WINTRICH 'S INTERRUPTED CHANGE OF SOUND 

When a pulmonary cavity contains fluid which is freely mobile 
and shifts its position readily with change in the posture of the 
patient, alternately occluding and leaving unoccluded the bron- 
chial communication of the cavity, there is frequently witnessed 
the alternate presence and absence of Wintrich 's change of sound 
upon changes in the attitude of the patient. When the posture 



136 



PHYSICAL DIAGNOSIS 



of the patient is such that the bronchial communication is situated 
above the level of the fluid, Wintrich's change of sound is demon- 
strable upon percussion; whereas with the shifting of the fluid 
and occlusion of the bronchus Avith change of posture the change 
of sound is abolished. As a result of the entrance of air beneath 
the surface of the fluid which is contained within the cavity, 




Fig. 57-A. — Illustrating the physical basis of Wintrich's interrupted change of sound. 

gurgling rales are not infrequently audible upon the change of 
the patient's posture. 

When this sign can be elicited, it is of service in determining 
whether the bronchial communication of the cavity is situated upon 
its base, or upon the anterior, posterior, or lateral wall of the 
cavity. If the bronchus communicates with the base of the cavity, 
with the patient in the upright attitude the fluid occupies the base 



PERCUSSION OF RESPIRATORY ORGANS 



137 



of the cavity and effectually prevents the change of sound of Wint- 
rich. Upon placing the patient in the dorsal decubitus, the mobile 
fluid occupies the posterior portion of the cavity and the sign of 
Wintrich reappears. If the bronchial orifice is situated on the 
posterior wall of the cavity, the opposite condition of affairs ob- 
tains, and the change of note is demonstrable in the erect position 
and is abolished in the dorsal decubitus. If, on the other hand, the 
change of sound is demonstrable in both the erect posture and in the 
dorsal decubitus, but is abolished upon placing the patient in the 
genupectoral position, the bronchial orifice is evidently situated 
upon the anterior wall of the cavity. If, finally, the change of 
sound persists in all three of the above-named attitudes, then 




Fig. S7-B. — Illustrating the physical basis of VVintrich's interrupted change of sound. 

the bronchial orifice is situated upon one of the lateral walls of 
the cavitj^, and the change of note is obliterated upon placing the 
patient upon the side of the orifice. 



FRIEDREICH'S RESPIRATORY CHANGE OF SOUND 

Friedreich noted that the tympany which is elicited upon per- 
cussion of a superficial pulmonary cavity with patent bronchial 
communication possesses a higher pitch during inspiration than 
during expiration. This change of pitch is explained upon the 
basis of the increased diameter of the chink of the glottis during 
inspiration, the glottic slit in this instance, in continuous com- 
munication through the bronchial system with the pulmonary 
cavity, acting as the true orifice of the cavity and its breadth 



138 PHYSICAL DIAGNOSIS 

determining the pitch of the percussion tympany during the two 
phases of respiration. Moreover, the increased tension of the 
walls of the cavity during inspiration causes a slight increase in 
the pitch of the percussion note, which at the same time loses a 
portion of its tympanitic quality. Of definite diagnostic value 
when present, this sign is rather difficult to elicit in most cases. 




Fig. 58-A. — Illustrating the physical basis of Gerhardt's change of sound. 

GERHARDT'S CHANGE OF SOUND 

"When a superficial pulmonary cavity is partially filled with 
mobile fluid, and when its vertical and horizontal diameters are 
unequal, there is noted a definite change in the pitch of the per- 
cussion tympany with changes in the posture of the patient. 
When the patient is so placed that the greater diameter of the 



PERCUSSION OF RESPIRATORY ORGANS 



139 



cavity is horizontal, the percussion note is of lower pitch than 
it is when the greater diameter of the cavity is vertical, as the 
result of the differences in the length of the air column which is 
set in vibration during percussion. Thus, it is observed that this 
sign can in the case of closed cavities be utilized in the estimation 
of the direction of the greater diameter of a cavity ; but, as in the 
case of open cavities similar changes of note are observed with 
changes of posture, it is essential in the first place to determine 




Fig. 58-B. — Illustrating the physical basis of Gerhardt's change of sound. 

through the signs which have already been described whether or 
not the cavity is closed. 

BIERMER'S PHENOMENON 

Biermer noted a change of sound in the presence of hydro- 
pneumothorax analogous to the change of sound of Gerhardt ; 
namely, that the tympanitic note elicited upon percussion over 
a hydropneumothorax was of lower pitch when the patient was 
placed in the recumbent posture, and changed to a note of higher 
pitch when the patient assumed the sitting posture. The varia- 
tion in this instance is attributable to the change in the relative 
diameters of the air-containing cavity, as a result of gravitation 
of the fluid to the most dependent portion of the sac. 



SKODAIC RESONANCE 

Skodaic resonance is a tj^mpanitic sound which is elicited upon 
percussion of a portion of the lung which is in a state of relaxa- 



140 PHYSICAL DIAGNOSIS 

■ * 

tion or of compression. This variety of tympany may be elicited 
in the presence of disease of the bronchi, alveolar disease, or in 
disease of organs adjacent to the lungs, as the pleura, peri- 
cardium, heart, or the abdominal viscera. Skodaic resonance is 
differentiated from tympany due to pulmonary excavation by the 
fact that the pitch of the tympanic sound is uniform and is not 
altered upon opening or closing the mouth or upon changes of 
posture. 

In respect to the relative frequency of the etiologic factors 
which are concerned in the generation of Skodaic resonance, pul- 
monary compression stands first and foremost, and is followed by 
alveolar disease, and by bronchial affections. 

In the presence of extensive pleural effusion the lung is 
elevated and is crowded into the superior portion of the pleural 
cavity, leading to compression and relaxation of the alveoli of 
the upper lobes. Hence, in this disease the examiner frequently 
encounters Skodaic resonance upon percussion of the thorax 
above the level of the fluid in these conditions. In the case of 
extensive pericardial effusion pressure is exerted upon the medi- 
astinal surface of the upper lobe of the left lung, leading to com- 
pression and relaxation of this portion of the organ and the 
production of Skodaic resonance upon percussion of the first 
and second left intercostal spaces. Upon the posterior surface 
of the thorax, on the contrary, below the angle of the left scapula, 
the examiner commonly encounters dullness upon percussion, 
associated with bronchovesicular or bronchial breathing and 
increased vocal fremitus, due to a compression of the inferior 
lobe of the left lung to such a degree that the air is in the main 
forced from the alveoli, constituting Bamberger's sign of this 
disease. Immense cardiac hypertrophy is not infrequently at- 
tended by Skodaic resonance, which is distributed along the 
superior and left lateral boundaries of the area of relative cardiac 
dullness. Occasionally, though b}^ no means frequently, Skodaic 
resonance is elicited over the superior portion of the thorax in 
the presence of upward displacement of the diaphragm by exces- 
sive intraabdominal pressure due to ascites, tympanites, or large 
abdominal tumor. 

Skodaic resonance is present in the case of certain affections 
of the pulmonary alveoli, when the latter contain simultaneously 
fluid and semisolid materials. These conditions are met during 
the first and the third stages of lobar pneumonia, during catar- 
rhal pneumonia, during pulmonaiy edema, and in pulmonary 



PERCUSSION OF RESPIRATORY ORGANS 141 

infarction of extensive distribution. The presence of dullness 
over both bases posteriorly with Skodaic resonance over the 
superior portions of the thorax anteriorly is very suggestive of 
catarrhal pneumonia. Hutinel and Paisseau hold that Skodaic 
resonance in the infraclavicular regions is the first intimation of 
the presence of infantile catarrhal pneumonia, making its advent 
before the development of impaired resonance is manifested over 
the bases posteriorly. 

When, in the development of acquired atelectasis due to bron- 
chial obstruction, the obstruction becomes complete, the air which 
is contained in the alveoli distal to the bronchial occlusion is 
gradually absorbed, and with the consequent relaxation of the 
pulmonary tissues, Skodaic resonance makes its appearance. 

WILLIAMS' TRACHEAL TONE 

Upon percussion of the apices of the lungs in the supraclavicu- 
lar and infraclavicular regions, in the presence of apical con- 
solidation the percussion sound frequently has imparted to it 
the tympany of the adjacent trachea, constituting the tracheal 
tone of Williams. As the fundamental cause of the sound is 
the vibration which is generated in the aerial content of the 
trachea, the tympany of AYilliams is subject to the variation .in 
pitch of Wintrich upon opening and closing the mouth. In the 
elicitation of the note, forcible percussion is employed over the 
supraclavicular and infraclavicular regions. 

AMPHORIC RESONANCE 

Amphoric resonance is a tympanitic note of clanging, echoing, 
metallic quality, and of decidedly longer duration than pure 
tympany. A similar resounding note is elicited upon striking 
the side of a barrel which is empty or partially filled with water, 
or upon speaking in a loud voice in an empty chamber with high 
ceiling or in a vaulted cellar. 

Amphoric resonance is generated in percussion of superficial 
pulmonary cavities of irregular configuration, and with smooth, 
tense walls, which are free from secretion. The sound is elicited 
over both open and closed cavities, and the pitch of the note 
varies with the vertical diameter of the cavity. Wintrich ex- 
plained the generation of the amphoric sound on the assumption 
of the creation during percussion of vibrations in the air content 
of varying amplitude, the more rapid overtones dying away 



142 PHYSICAL DIAGNOSIS 

■ « 

more quickly than does the fundamental tone of greater ampli- 
tude, producing an echoing sound of considerable duration. 

The intensity of the amphoric percussion sound is influenced 
by the thickness of the walls of the cavity, by the distance of the 
cavity from the thoracic wall, by the thickness of the thoracic 
wall, and by the force of the percussion blow. In the case of 
open cavities, the intensity is increased when the mouth is opened. 

THE CRACKED-POT SOUND (BRUIT DE POT FeLE; 
MONEY-CHINK RESONANCE) 

The cracked-pot sound is a variety of tympany in which the per- 
cussion note bears some resemblance to the sound which is produced 
upon tapping the side of a cracked metal jar, or to the muffled 
chink of coins, whence the name money-chink resonance. Neither 
of the above comparisons gives a true conception of the quality 
of the sound, which is hissing rather than metallic in quality; 
and its quality is more aptly imitated by the sound which ensues 
upon suddenly striking the clasped palms upon the knee with the 
sudden escape of the air confined between the palms. 

The essential element in the production of the cracked-pot 
sound is the sudden expulsion of air from a portion of the lung 
or pleural cavity, whether it be from a pulmonary cavity with 
free bronchial communication, from a relaxed portion of the 
lung, or from a pneumothorax with communicating bronchial 
fistula. Hence, the sound bears a variable significance, depending 
upon the concomitant signs in the given case. In infants and 
young children a cracked-pot sound possesses little significance, 
as it is frequently a normal phenomenon upon percussion of the 
thin, resilient chests of this class of subjects. 

In the elicitation of the cracked-pot sound the percussion blows 
should be delivered slowly and forcibly during expiration, with 
the subject's lips parted, the examiner's ear meanwhile being 
held near the lips of the patient. 

In the case of pulmonary cavities the sound is only elicited 
in cavities possessing a patent bronchial communication, whence 
it follows that the cracked-pot sound is attended by the change 
of sound of Wintrich. In the event that the cavity contains fluid 
which, upon change of posture, causes interruption of the change 
of sound of Wintrich, the cracked-pot sound also disappears. A 
further essential for the elicitation of the cracked-pot sound from 
pulmonary cavities is that the cavity be situated in the periphery 



PERCUSSION OF RESPIRATORY ORGANS 143 

of the lung and that the thoracic parietes be sufficiently thin and 
elastic to permit the expulsion of the air from the cavity during 
the delivery of the percussion blow. Grancher has noted the dis- 
appearance of the cracked-pot sound over superficial cavities 
after a few percussion blows and its reappearance following 
several deep inspirations. He assumes that the air is totally ex- 
pelled from the cavity during the primary percussion, and that 
the sound only again becomes evident upon replacement of the 
aerial content of the cavity during deep inspiration. In the case 
of a cavity containing fluid or viscid secretion, abolition of the 
sound may be due to bronchial occlusion. 

In the presence of apical pneumonia, apical consolidation of 
chronic phthisis, or in compression of the superior lobe of the 
lung by an immense pleural effusion it is occasionally possible to 
obtain a cracked-pot sound upon percussion of the anterior thor- 
acic wall in the first and second intercostal spaces. In this case 
the cracked-pot sound is likely to be attended by the tracheal 
tone of Williams. 

During the first and third stages of lobar pneumonia the 
cracked-pot sound is occasionally demonstrable in the infra- 
clavicular and mammary region upon the side of the disease. 
Cockle has observed the sign in simple catarrhal bronchitis in 
children ; and Rollet has encountered it in bronchopneumonia. 

In the case of open pneumothorax, whether the fistulous open- 
ing be external upon the surface of the thorax, or internally as a 
result of rupture of a tuberculous cavity of the lung, the cracked- 
pot sound is frequently to be elicited. Nothnagel, Oppolzer, 
Frerichs, and Eichhorst have encountered the sound in associa- 
tion with this disease. 

"When the cracked-pot sound is encountered at the apices, it is 
plainly a question of pulmonary compression or of pulmonary 
cavity with bronchial communication, which is probably tuber- 
culous in origin. In cases of tuberculous origin Loeb holds that 
the sound is most frequently encountered over the right apex. 

Bronchiectatic dilatations of the bronchi furnish all of the 
physical requirements for the generation of the cracked-pot 
sound, the chink of the glottis in this instance playing the role of 
the constricted orifice through which the air is expelled during 
percussion. However, bronchiectases are usually too deeply 
seated in the pulmonary parenchyma to be materially influenced 
by the force of the percussion blow, and, moreover, bronchiectasis 
is not a disease which is commonly encountered. 



144 PHYSICAL DIAGNOSIS 

GAIRDNER'S COIN TEST (BELL TYMPANY; ANVIL TEST) 

In cases of pneumothorax, when the stethoscope is applied to 
the base of the thorax posteriorly while an assistant percusses 
the anterior surface of the thorax with two coins employed as 




59. — Illustrating bell tympany, or Gairdner's coin test. 



pleximeter and plexor, respectively, an echoing, metallic sound is 
appreciated through the stethoscope, possessing a ringing quality 
analogous to the distant ring of a hammer upon an anvil. 



CHAPTER V 
AUSCULTATION 

Object and Technic. — Auscultation is the act of listening to 
sounds which are generated within the thorax or abdomen with 
the unaided ear or with a specially devised instrument, the 
stethoscope. When the unaided ear is employed, the procedure 
is termed immediate auscidtaiion in contradistinction to instru- 
mental auscultation, which is termed mediate auscultation. Auscul- 
tation, which is the most important single method of physical 
examination, is employed in the study of the lungs, heart, and 
digestive organs, and in eliciting certain vascular phenomena. 

Stethoscopes are monaural and binaural, as they are equipped 
with one or two earpieces, respectively. The monaural instrument 
is seldom employed by American clinicians, having yielded place 
to several types of binaural stethoscope. The modern binaural 
stethoscope consists of a bell or chestpiece of hard rubber or metal, 
which is connected with the earpieces by rubber tubing, the prin- 
ciple involved being the clear transmission of sound from the 
subject to the ear of the examiner and the exclusion as far as pos- 
sible of all extraneous noises. In the Bowles stethoscope the bell 
is replaced by a chestpiece containing a vibrating diaphragm. 
This type of instrument is very useful in the examination of bed- 
ridden patients and during hasty examination of female subjects, 
when the chestpiece is readily slipped beneath the clothing. Stetho- 
phones have been employed in the practice of auscultation, the 
object of the instruments being to magnify the intensity of the 
sounds which are elicited ; but their use should be guarded, as they 
are poor conductors of high-pitched sounds, and from a clinical 
standpoint the clearness and quality of the sounds are of greater 
importance than is an artificial magnification of the intensity" of 
the sounds elicited. In the selection of a stethoscope, whatever 
type is adopted, care should be exercised to secure an instrument 
whose bell and tubing are sufficiently heavy to exclude as far as 
possible extraneous noises and whose earpieces fit snugly in the 
ears of the examiner. 

Immediate Auscultation. — In the practice of immediate aus- 
cultation the ear of the examiner is applied directly to the part 

145 



146 



PHYSICAL DIAGNOSIS 



under examination, only a thin garment or a towel intervening 
between the ear and the chest wall. The position of the patient 
should conform to that which obtains during mediate ausculta- 
tion. 

Mediate Auscultation. — In the practice of mediate auscultation 
the bell of the stethoscope is applied firmly and evenly to the 
chest wall, but without the exertion of undue pressure. The bell 
of the instrument is retained in position by grasping it near the 







Fig. 60. — Hawksley's 
monaural stethoscope. 



Fig. 61. — Bowles 
stethoscope. 



Fig. 62. — Binaural 
stethoscope. 



base with the index finger and the thumb. No article of wearing 
apparel should be permitted to intervene between the bell of the 
instrument and the surface of the thorax. 

During auscultation of the respiratory organs the examiner 
should note the character of the sounds which are generated 
during quiet, moderately deep, and forced respiration, being ever 
on the alert for any deviation from the normal sounds. 



AUSCULTATION OF RESPIRATORY ORGANS 



147 



Auscultation is practiced by preference with the patient in the 
sitting posture. During auscultation of the anterior surface of 
the thorax the arms of the patient should hang naturally at the 
sides, and his position should be natural and free from undue 
muscular tension. In auscultation of the axillary and infra- 
axillary regions the patient should raise the arms laterally only 
so far as is necessary to ensure a free access to this portion of the 
thorax. During auscultation of the posterior aspect of the thorax 
the patient should incline the trunk forward and clasp the arms 
across the chest to ensure a wide separation of the scapulse. 




Fig. 63. — Auscultation of thorax. 



Auscultation of the thorax should be practiced methodically, 
the examiner progressing downward from the apices to the bases 
of the lungs. In each instance the sound which is elicited upon 
one side should be compared with the sounds elicited over the 
corresponding area upon the opposite side of the thorax. Wan- 
dering and hasty auscultation of the thorax, without comparison 
of the sounds upon the two sides, is a productive source of error 
in physical examinations. 

The ear of the examiner should be trained to disregard all ex- 
traneous noises, such as the friction produced by the rubbing 
together of the tubes of the instrument, the contact of the hand 
with the instrument, and crepitation due to contact of the bell 



148 PHYSICAL DIAGNOSIS 

■ * 

of the stethoscope with a hairy chest wall. This last annoying 
feature may be eliminated by moistening the bell of the instru- 
ment prior to its application to a hairy chest wall. The beginner 
in auscultation usually experiences some difficulty in separating 
the pulmonary and the cardiac sounds; but concentration and 
practice will enable him to disregard the one while studying the 
other. 

NORMAL RESPIRATORY SOUNDS 

Upon auscultation of the various regions of the thorax of the 
normal subject three types of respiratory murmur are encountered ; 
namely, hronchial hreathing, vesicular 'breathing, and hroncho- 
vesicular 'breathing. 




Fig. 64. — Normal distribution of bronchial and bronchovesicular breathing. Anterior 

thoracic surface. 

Bronchial Breathing". — Bronchial breathing is a blowing, tubu- 
lar sound, the inspiratory and expiratory phases of which are as 
a rule of equal duration, though occasionally expiration is slightly 
prolonged. The inspiratory and expiratory phases of the murmur 
are separated by a distinct interval; and the intensity and pitch 



AUSCULTATION OF RESPIRATORY ORGANS 



149 



of the two phases are different, for physical reasons Avhich will 
be detailed in succeeding paragraphs. 

Bronchial breathing in its maximum purity and intensity is 
elicited upon auscultation of the larynx and trachea, over the site 
of production of the aerial Avhorls which call the sounds into 
being. The sound is also commonly audible in the interscapular 
regions in the area situated between the seventh cervical and 
fourth dorsal vertebra, and over the manubrium sterni anteriorly, 
the latter two levels corresponding to the level of the tracheal 
bifurcation. These are the regions of the thorax in which bron- 
chial breath sounds are encountered during tranquil respiration. 




Fig. 65. — Normal distribution of bronchial and bronchovesicular breathing. Posterior 

thoracic surface. 

In the presence of extreme grades of dyspnea, with marked in- 
crease in the force and depth of the respirations, it is not un- 
common for bronchial breath sounds to become audible over the 
entire thoracic surface. 

When during inspiration the inspired air passes through the 
orifice of the glottic slit and enters the wider cavity of the larynx 
beyond, aerial whorls are generated in the air content of this 
cavity, whorls which are conducted downward into the trachea 
and larger bronchi in the form of the inspiratory phase of bron- 
chial breathing. Similarly, Avhen during expiration the expired 
air passes through the chink of the glottis into the broader 



150 



PHYSICAL DIAGNOSIS 



pharyngeal cavity beyond, similar whorls are induced with the 
production of the expiratory phase of bronchial breathing. 

As the genesis of the sound in each instance lies in the 
passage of air through the glottic slit, it is easy to comprehend 
the influence of the diameter of this opening upon the intensity 
and the pitch of the two phases of bronchial respiration. The 
physical laws governing aerial currents teach us that the in- 
tensity of the sound engendered by such currents varies in direct 
proportion with the degree of stenosis or narrowing of the orifice. 
Hence, the expiratory phase of bronchial respiration, corre- 



4_iLJ. 




Fig. 66. — Physical basis of pathologic physical signs upon percussion and auscultation 
of the thorax, 

A, cracked-pot sound; B, Biermer's phenomenon; C, pectoriloquy; D, lung-fistula 
sound; i, cracked-pot sound; 2, Wintrich's change of sound; 5, Friedreich's change of 
sound; 4, bronchial or amphoric respiration; 5, whispering pectoriloquy. 



sponding to the narrowing of the glottis at this time, is more 
intense than the inspiratory phase of bronchial breathing. Simi- 
larly, since according to the physical laws governing the pitch 
of sounds generated in this manner the pitch is in direct propor- 
tion to the size of the opening, one readily understands that the in- 
spiratory phase of bronchial breathing, corresponding to the 
widening of the chink of the glottis during inspiration, is of 
distinctly lower pitch than is the expiratory phase. 

The tendency for these vibrations to be conducted downward 



AUSCULTATION OF RESPIRATORY ORGANS 151 

throughout the bronchial system and outward to the thoracic wall 
by way principally of the aerial content of these tubes and 
secondarily by the walls of the tubes themselves, is combated by 
the great mass of aerated pulmonary parenchyma which inter- 
venes between the principal bronchi and the thoracic walls. In 
the presence of extensive consolidation of the pulmonary alveoli, 
however, and in the presence of extensive cavitation of the lung 
with free communication with the bronchial system, the bronchial 
sounds generated in the larynx are conducted to the thoracic wall 
with an intensity and clearness which justifies the descriptive 
term of ''tubular breathing." 

Vesicular Breathing. — ^Upon auscultation of the infraclavicular 
and mammary regions anteriorly, of the axillary and infraaxil- 
lary regions laterally, and of the infrascapular regions poste- 
riorly, regions of the thoracic surface which overlie portions of 
the lungs which are comparatively remote from the principal 
bronchial tubes, the respiratory sounds possess a soft, breezy 
sound of low pitch, which is termed vesicular or alveolar breath- 
ing. The murmur consists of two phases, inspiratory and expira- 
tory, which are separated by a short interval. The inspiratory 
murmur is maintained approximately three times as long as is 
the expirator}^ murmur. The quality of vesicular breathing has 
been compared to the sound produced by the soft rustling of the 
leaves of a tree when agitated by a gentle breeze. The quality of 
the sound can also be rather closely simulated by approaching the 
lips nearly in contact and inspiring strongly. 

The physical genesis of the vesicular murmur has not as yet 
been accounted for in an adequate manner. Laennec erroneously 
attributed the sound to the rubbing of the inspired and expired 
air against the walls of the bronchi and pulmonary alveoli, an 
explanation which rests upon no adequate physical basis. Blakis- 
ton held that during inspiration the involuntary muscular fibers, 
disposed in a circular manner around the walls of the smaller 
bronchioles, contracted with the consequent production of partial 
stenosis of these tubules with the generation of the vesicular 
murmur, a theory which is not substantiated entirely from either 
the physiologic or physical point of view. Leaning would have 
us believe that the murmur is a purely muscular sound, generated 
by contraction and relaxation of the smooth muscle bands of the 
bronchioles during inspiration and expiration. Gerhardt attrib- 
uted the vesicular murmur to vibrations of the alveolar walls 
during inspiration. At the present time the most probable ex- 



152 PHYSICAL DIAGNOSIS 

planation of the sound, it would seem, is tliat of Baas and Pen- 
zoldt, who state that the vesicular, murmur is merely bronchial 
breathing softened in its transmission from the larynx along the 
aerial column contained in the trachea and bronchi, mingled with 
the soft crepitation of innumerable pulmonary alveoli during 
their inflation and subsequent collapse. 

Whatever may be the precise genesis of the vesicular breath 
sound, clinical experience has taught us to construe its presence 
to mean that in any region of the thorax where it is encountered, 
the pulmonary alveoli and bronchioles are permeable to air. It 
does not foUoAV from this, however, that its presence assures a 
normal condition of these structures. In the small, disseminated 
patches of consolidation attending miliary tuberculosis of the 
lungs and lobular pneumonia it is possible for the intervening 
aerated areas of the lung to suppress any enfeeblement of the 
murmur which might arise as the result of the exclusion of the 
air from the minute and scattered areas of alveolar consolidation. 

The intensity of the vesicular murmur is dependent upon the 
force of the respiratory efforts and the thickness of the thoracic 
walls in the normal subject. The influence of the depth of the 
respiratory act upon the murmur is Avell illustrated upon aus- 
cultation of the thorax during Cheyne-Stokes respiration, when 
the intensity of the vesicular murmur will exhibit all gradations 
from accentuation of the murmur at the height of the dyspneic 
period to its total abolition during the period of comparative 
apnea. In children and in the female subject, owing to the thin- 
ness and elasticity of the thoracic ]3arietes the vesicular murmur 
is more intense than is the case in the adult male subject. The 
age has a direct bearing upon the intensity of vesicular breath- 
ing. Up to the twelfth year of life, vesicular respiration is more 
intense than it is subsequent to that age ; while in the aged 
subject there is a progressive diminution in the vesicular element 
of the respirator}" sounds, which come to approach the quality 
of bronchial breathing or bronchovesicular breathing. 

The pitch of vesicular breathing varies with the age and sex 
of the subject. It is uniformly of higher pitch in the infant 
and young child than it is in the adult subject ; and it is of higher 
pitch in the female than in the male subject. The variation in 
the pitch of the murmur is in each of these instances caused by 
the smaller diameter of the glottic slit in the first class of sub- 
jects. Again, in the aged subject, without regard to sex, there is 



AUSCULTATION OF RESPIRATORY ORGANS 153 

an increase in the pitch of vesicular breathing, the result in this 
instance of senile rarefaction of the pulmonary tissues. 

Bronchovesicular Breathing". — This type of respiration, as its 
name implies, combines the qualities of bronchial and of vesicu- 
lar breathing. It is audible over regions of the normal thorax in 
which the larger bronchi are in fairly close proximity to the 
thoracic wall, but are nevertheless covered by aerated pulmonary 
tissue. Thus, bronchovesicular breathing is normally audible 
over the lower portion of the manubrium sterni and adjacent to 
its right lateral border anteriorly, and in the interscapular regions 
posteriorly at the level of the fourth dorsal vertebra. 

ABNORMAL RESPIRATORY SOUNDS 

In the presence of disease of the respiratory organs, various 
modifications of the normal respiratory sounds are encountered. 
The alteration may consist of the presence of bronchial or 
bronchovesicular breathing in a region of the thorax where it is 
not normally present; of the assumption by bronchial breath 
sounds of certain cavernous or amphoric qualities which are not 
normally attributable to them; of variations in the intensity of 
the vesicular murmur in regions of the thorax where it is nor- 
mally present ; or of variations in the frequency or rhythm of the 
respiratory sounds. 

Bronchial Breathing.^ — When bronchial breath sounds are de- 
tected in a region of the thorax where they are not normally 
audible, it most frequently points to consolidation of the lung, 
the solidification conducting the murmur from the large bronchi 
to the surface of the thorax. Other factors Avhich act similarly 
comprise pulmonary compression and collapse, hemorrhagic in- 
farction, cirrhosis of the lung, enlarged bronchial glands, a tumor 
overlying a large bronchus, or a pulmonary cavity situated near 
the chest wall with a free bronchial communication. 

Bronchial breathing which is referable to a cavity with patent 
bronchial communication frequently has a peculiar hollow quality 
engrafted upon it to which the term cavernous hreathing is ap- 
plied. In this subtype of bronchial breathing expiration is fre- 
quently of lower pitch than is inspiration. Similarly, a cavity 
with patent bronchial communication or a pneumothorax with an 
open bronchial fistula often gives rise to bronchial breathing of 
rather musical quality, closely simulating the sound which is 
generated by gently blowing across the mouth of an empty bottle, 
amphoric hreathing. 



154 PHYSICAL DIAGNOSIS 

Vesicular Breathing^. — In disease of the respiratory organs the 
intensity and rhythm of the normal vesicular murmur is fre- 
quently so altered as to possess definite diagnostic significance. 

Diminution in the intensity or entire abolition of the vesicular 
murmur is normal in aged subjects and in subjects with very thick 
chest walls. The murmur is also diminished in the presence of 
painful diseases of the chest wall such as incipient pleurisy and 
pleurodynia, which cause the patient to inhibit the respiratory 
excursions of the chest. A similar diminution occurs with moderate 
pleural thickening, edema of the lung, the early stage of lobar 
pneumonia, and in the presence of a closed pneumothorax. 

Abolition of the vesicular murmur is noted over a region of the 
thorax in which the main bronchus is occluded, over a large pleural 
effusion, and over a pulmonary cavity which is filled with fluid. 

Increased Intensity (Puerile Breathing). — Exaggeration of the 
vesicular murmur is noted over a lung which is the site of com- 
pensatory emphysema due to crippling of the opposite lung, over 
a circumscribed portion of a lung which is expanding vicariously 
to compensate for consolidation in an adjacent focus, in catarrhal 
inflammations of the smaller bronchioles, and during the dyspnea 
of imperfectly compensated cardiac disease. 

Prolongation of the expiratory phase of the vesicular murmur 
accompanies hypertrophic emphysema and bronchial asthma. In 
these states the alteration in the phases of the sound is noted over 
both sides of the thorax; and in the case of asthma expiration is 
dotted with rales. Unilateral prolongation of the expiratory 
phase at an apex is suggestive of incipient pulmonary tuberculo- 
sis, particularly if noted at the left supraclavicular fossa. 

Cog-wheel Breathing. — In certain diseases of the respiratory 
organs the respiratory murmur, and particularly the inspiratory 
phase of the murmur, occurs in a series of short gasps or jerks, 
closely simulating the sound emitted by a sobbing child. This 
jerking or cog-wheel modification of the vesicular murmur is 
a valuable sign of incipient phthisis. It is noted with far less 
constancy in hysteria, bronchial asthma, chorea, local catarrhal 
conditions of the bronchioles, in the pain of a fractured rib, 
pleurodynia, and pleurisy. 

Bronchovesicular Breathing. — When encountered in an area of 
the thorax where it is not normally audible, this type of respira- 
tion points to a moderate degree of the same pathologic changes 
which produce frank bronchial breathing. It is a sign of partial 



AUSCULTATION OF RESPIRATORY ORGANS 155 

or incomplete consolidation, as in the early stage of pneumonia or 
phthisis, or of a cavity or a solid tumor of the lung which is 
covered by normal crepitant pulmonary tissue. 

VOCAL RESONANCE 

Vocal resonance is the transmission of inarticulate or articu- 
late sound to the ear of the examiner upon auscultation of the 
thorax during the act of phonation. In eliciting the phenomena 
of vocal resonance, the bell of the stethoscope is applied firmly 
and evenly to the surface of the thorax while the patient is 
directed to count ''One, two, three," or to repeat the words 
"ninety-nine" in a voice of uniform intensity and with the face 
turned from the examiner. According to the aim of the examina- 
tion, the patient repeats the words either aloud or in a whisper. 
In either event, it is essential that the intensity of the voice re- 
main uniform throughout the examination. In the course of the 
examination the intensity of the sounds elicited from various 
regions of the thorax should be studied, and the intensity upon 
symmetrical regions should be carefully compared. 

The intensity of vocal resonance presents regional variations 
in the various regions of the thorax which correspond accurately 
to the regional variations in the intensity of vocal fremitus in the 
normal subject. As in the case of vocal fremitus, vocal resonance 
is elicited in its maximum intensity and purity upon auscultation 
of the larynx. Upon auscultation over the thyroid cartilage the 
sound is so intense that it is frequently painful to the ear, 
laryngophony. Moreover, the quality of the voice as appreciated 
upon auscultation is observed to have quite completely altered in 
quality. It possesses upon auscultation a distinct nasal quality, 
which is rather closely simulated Avhen the subject speaks with 
the nares closed or with a membrane stretched tightly across the 
lips. 

The causes of the alteration in the quality of the voice are 
multiple, being due to the propagation of the vocal vibrations 
across the solid cartilages of the larynx instead of through free 
air; to the fact that the propagation does not follow the direction 
of the molecular oscillations, but occurs perpendicularly to them ; 
and to a simultaneous mingling of the vibrations of the laryngeal 
cartilages with the vocal vibrations (Eichhorst). 

Upon auscultation of the median line of the root of the neck 
and the episternal notch, corresponding to the course of the 



156 PHYSICAL DIAGNOSIS 

■ • 

trachea, the vocal vibrations possess great clearness and intensity, 
tracheophony, but which does not equal the purity of the resonance 
as elicited over the larynx. Again, upon auscultation of the 
interscapular region at the level of the fourth dorsal vertebra, over- 
lying the origin of the principal bronchi, the intensity of the reso- 
nance is also extremely pure, broncho phony. 

Upon auscultation of the infraclavicular, mammary, axillary, 
infraaxillary, and infrascapular regions, regions of the thorax 
which overlie crepitant pulmonary tissue in which the larger 
bronchi are comparatively remote from the thoracic surface, the 
examiner appreciates in the normal subject only certain rumbling, 
inarticulate sounds, which arise in the vocal cords and are trans- 
mitted downward into the lung and to the thoracic surface by the 
air column of the trachea and bronchi and the pulmonary paren- 
chyma. 

As in the case of vocal fremitus, again, the intensity of vocal 
resonance depends upon the intensity and pitch of the voice, and 
upon the thickness and elasticity of the thorax ; whence it follows 
that it is relatively less intense in the case of young children and 
in the female subject. In the aged subject, on the contrary, owing 
to wasting of the investing musculature of the thorax and to the 
progressive calcification of the bronchial cartilages, vocal reso- 
nance becomes progressively more intense with increasing age. In 
this class of subjects the sound very frequently assumes a quaver- 
ing, nasal quality, analogous to egophony in younger subjects, on 
account of the natural quaver of the senile voice. 

PATHOLOGIC VARIATIONS 

As the intensity of vocal fremitus is modified by various lesions 
of the thoracic viscera, so also vocal resonance, the auscultatory 
equivalent of vocal fremitus, under similar circumstances exhibits 
variations which, in the main, are very similar and closely akin 
to the variations in vocal fremitus. In addition, in the presence 
of certain diseases of the bronchopulmonary system, vocal reso- 
nance exhibits definite and more or less pathognomonic modifi- 
cations in its quality. 

Diminution or Absence. — The intensity of vocal resonance is 
impaired in the presence of hypertrophic emphj^sema or com- 
pensatory emphysema, oAving to the distention of the lung 
incident to these conditions. It is similarly diminished or abol- 
ished in the iDresence of pleural thickening, moderate pleural 



AUSCULTATION OF RESPIRATORY ORGANS 157 

effusion, and bronchial stenosis. A pulmonary cavity containing 
fluid causes abolition of vocal resonance in the area in which it lies. 
"While in the case of pleural effusion the usual finding is abolition 
of vocal resonance over the distribution of the fluid and exaggera- 
tion of the resonance above the limit of the fluid, yet in the 
presence of pleural adhesions which traverse the fluid effusion, 
it is possible for vocal resonance to be manifest in circumscribed 
portions of the thoracic surface overlying the effusion. 

Increased Vocal Resonance. — Vocal resonance is increased by 
the same factors which cause an increase of vocal fremitus; 
namely, consolidations, pulmonary compression, and cavities with 
free bronchial communication. The various gradations of in- 
creased vocal resonance are designated by different names. 

Bronchophony is a form of increased vocal resonance in which 
the transmitted voice is very distinctly audible, sounding as if it 
were very near the ear. However, the speech is not articulate as 
it is in the next ascending grade, pectoriloquy. Bronchophony 
points to dense consolidation, particularly to consolidation which 
overlies or is superimposed upon one of the principal bronchi. 

Pectoriloquy, the transmission of the articulate voice upon aus- 
cultation, is evidence of a very dense consolidation overlying a 
principal bronchus, or of a pulmonary cavity or pneumothorax 
with free bronchial communication. With less frequency pectoril- 
oquy is elicited upon auscultation of a portion of the lung which 
is compressed by a pleural effusion. In the cases in which the 
voice is transmitted with great distinctness it is very suggestive of 
a pulmonary cavity. 

Whispering pectoriloquy, the transmission of the articulate 
whisper upon auscultation, represents the highest reflnement of 
vocal resonance ; and when elicited it is almost conclusive evidence 
of the presence of a pulmonary cavity with patent bronchial com- 
munication or of pneumothorax with bronchial fistula. In the 
normal subject the whispered voice is audible as such only upon 
auscultation immediately over the trachea. In extensive consolida- 
tions and conditions of pulmonary compression and collapse the 
whispered voice is frequently audible but is not articulate. An 
articulate whisper upon auscultation is very good evidence of a 
pulmonary cavity with free bronchial outlet. 

Baccelli's Sign. — The whispered voice is transmitted through 
a serous pleural effusion, but is not transmitted through a purulent 
effusion. This sign is employed in differentiating between the two 
types of pleural effusion. While it is often a valuable means of 



158 PHYSICAL DIAGNOSIS 

■ * 

differentiation, it not infrequently is not demonstrable, as the 
whispered voice frequently is not transmitted through a serous 
effusion of large extent. 

MODIFIED VOCAL RESONANCE 

Egophony. — In the presence of moderate pleural effusion, upon 
auscultation of the thorax immediately above the level of the 
fluid during phonation, the vocal sounds are apt to assume a 
peculiar, quavering, nasal tone, somewhat resembling the plain- 
tive bleat of a goat. This peculiar sound constitutes the egoph- 
ony of Laennec. Most readily elicited posteriorly near the 
angle of the scapula, the note is occasionally audible upon auscul- 
tation of the anterior surface of the thorax above the level of a 
pleural effusion. 

The persistence of egophony in connection with pleural effu- 
sions is very variable. When an effusion of medium grade under- 
goes rapid augmentation, the egophony soon disappears; and 
when an extensive effusion is undergoing resorption, the sign 
appears with the gradual diminution in the fluid. 

The cause of the sound is a moderate compression of the bronchi 
due to pulmonary compression, a compression which leads to 
partial stenosis, yet to a stenosis which can readily be overcome 
by the force of the vocal vibrations (Eichhorst). Hence, the 
sign disappears whenever the compression becomes too strong, as 
well as when the compression has been removed. 

Commonly encountered in connection with pleurisy with effu- 
sion, egophony is encountered with less constancy over areas of 
pulmonary collapse and in pulmonary compression in the pres- 
ence of the consolidation of lobar pneumonia. 

Amphoric Vocal Resonance; ( Amphorophony ; Cavernous 
Voice). — In the presence of a large superficial pulmonary cavity 
with bronchial communication or of pneumothorax with a com- 
municating bronchial fistula, the spoken voice upon auscultation 
frequently has imparted to it an echoing, metallic quality, the 
sound prolonging itself beyond the emission of the spoken word. 
The phenomenon is analogous to the amphoric character of the 
respiratory murmur and of the amphoric percussion sound under 
similar circumstances and obeys the same physical laws which 
govern the production of the peculiar quality of the sounds in these 
instances. The echoing, cavernous quality of the spoken voice 
under these circumstances constitutes amphoric vocal resonance, 



AUSCULTATION OF RESPIRATORY ORGANS 159 

amphorophony, or the cavernous voice. When elicited, it con- 
stitutes a reliable sign of a cavity containing an air column which 
vibrates simultaneously with the waves reaching it from the 
vocal cords. 

ADVENTITIOUS SOUNDS 

New, superadded, or adventitious sounds, which are engen- 
dered in pathologic states of the organs of respiration, may 
originate in the larynx, trachea, bronchi, lungs, or in the pleural 
cavity. They comprise various types of rales, the metallic tinkle, 
the succussion sound, the lung-fistula sound, and the pleural 
friction sound. 

RALES 

Rales are adventitious sounds which are generated in the 
larynx, trachea, bronchi, bronchioles, or pulmonary alveoli, as 
a result of interference with the free ingress and egress of air 
during inspiration and expiration. The lesion which is respon- 
sible for the production of rales, and which will be studied more 
in detail in connection with the detailed description of the various 
types of rales, may consist in a diminution of the lumen of the 
air passage by compression from without, or by turgescence of 
the mucous membrane within; it may be an obstacle imposed by 
the presence of serum, mucus, pus, or blood within the bronchial 
tubes; or it may consist in the cohesion of the walls of the term- 
inal bronchioles and alveoli, which are glued together by a coat- 
ing of tenacious secretion or fibrinous exudate. 

Rales are classified primarily as dry rales and moist rales, 
depending upon whether or not moisture is, in the opinion of the 
examiner, the essential factor in their production. 

Dry rales, or rhonchi, which are invariably signs of stenosis, are 
produced by an obstacle to the free ingress and egress of air 
during respiration in the form of varying degrees of stenosis 
of the air passages, whether these passages be narrowed by the 
presence upon their walls of accumulations of tenacious secretion; 
whether the bronchial lumen be diminished by turgescent swelling 
of the mucous membrane ; or whether the constriction be due to 
external pressure exerted upon the bronchial tube by bands of 
adhesions or enlarged thoracic viscera. The generation of the sound 
in each instance is caused by the passage of the inspired or expired 
air through a bronchial stenosis into a wider portion of the tube 



160 



PHYSICAL DIAGNOSIS 



beyond, with the consequent production of aerial whorls. The 
quality of the rale is dependent for this reason upon the size of the 
bronchus in which it is generated and the diameter of the constric- 
tion which is the causative agent. 

Upon the acoustic influences of these two factors, it is possible 
to subdivide dry rales into sonorous rales, of low pitch, and snor- 
ing, often musical quality; and sihilant rales, of high pitch, and 
hissing, whistling, or squeaking quality. Now, since only a very 
moderate turgescence of the mucous membrane of the smaller 
bronchi and bronchioles, or the presence of even minimal amounts 




Fig. 67. — Illustrating the physical basis of pathologic physical signs upon ausculta- 
tion of the thorax. A, Sonorous rales; B, sibilant rales; C, metallic tinkle, or succussion 
sound; J, gurgling or bubbling rales; 2, coarse or mucous rales; j, fine or subcrepitant 
rales; 4, crepitant rales. 

of secretion upon the walls of these tubes produces considerable 
stenosis in these small passages, and as their caliber is so limited 
that the distal portion of the tube cannot act in any considerable 
degree as a resonating chamber for the aerial whorls which are 
called into being by the passage of the air through the constricted 
portion, sibilant rales are practically confined to the distribution 
of the smaller bronchi and bronchioles, while sonorous rales are 
produced only in the larger bronchi, the trachea, and the larynx. 
Dry rales are most frequently audible during inspiration ; less 
frequently they are audible during inspiration and expiration ; and 



AUSCULTATION OF RESPIRATORY ORGANS 161 

very infrequently indeed are they audible during expiration alone. 
Dry rales, and this is true of moist rales as well, are frequently 
audible at some distance from the region of the thorax which over- 
lies the site of their generation ; but they always present a point of 
maximum intensity, which is situated over the portion of the 
bronchial system in which they are produced. When dry rales are 
encountered universally over the thorax, as is the case in bronchial 
asthma, it is commonly observed that sonorous rales are audible in 
the main during the first half of inspiration; whereas the sibilant 
rales come to the fore during the latter half of this act, as a result 
of the progressive penetration of the inspired air to the ultimate 
ramifications of the bronchial system. If the rales are audible 
also during expiration, the opposite sequence of events is observed. 
The preponderance of dry rales during inspiration and their fre- 
quent absence during expiration is doubtless in intimate relation 
with the rapidity of the aerial current through the bronchial system 
during the two phases of the respiratory cycle. In order that 
whorls of sufficient intensity may be produced in the air passages 
to produce sound, it is essential that the air pass the stenosis with a 
fair degree of rapidity, a physical state which obtains during inspi- 
ration to a much greater degree than it is present during expiration. 
This assumption is further substantiated by the fact that dry rales 
are frequently inaudible during tranquil respiration, to come out 
clearly during deep inspirations upon the part of the patient. 

The relative pitch of dry rales is very readily appreciated even 
by the inexperienced examiner, the high pitched, squeaking, whist- 
ling sibilant rales contrasting markedly with the deep snoring of 
the sonorous rales. This variation in pitch possesses in this manner 
a distinct localizing value in diagnosis. 

The intensity of dry rales varies with the force of the respiratory 
movements, with the degree of stenosis which engenders them, with 
the site of their production in relation to the thoracic wall, and with 
the thickness of this wall. When dry rales of considerable initial 
intensity are generated in the depth of the lung, where they are 
covered by thick masses of aerated pulmonary parenchyma, the 
intensity is greatly masked in the transmission of the rales to the 
thoracic surface. When, on the contrary, rales are generated in 
bronchial tubes of more superficial distribution, their intensity is 
as much greater upon auscultation, and they are frequently at- 
tended by rhonchal fremitus upon palpation. 

Dry rales assume a special intensity and a distinct change in 
quality when they are engendered in a bronchus which terminates 



162 PHYSICAL DIAGNOSIS 

■ * 

in portions of the lung which are the seat of compression and col- 
lapse, and when the bronchus terminates in a pulmonary cavity 
situated in the periphery of the lung. In this instance the pul- 
monary excavation acts as a resonating chamber for the bronchial 
vibrations, with the production of the consonating rales of Skoda. 
The rales in this case are attended by blowing, bronchial breathing 
and amphoric resonance upon percussion over the cavity. 

Dry rales are audible in the earliest stages of bronchial inflamma- 
tion as a result of moderate turgescence of the bronchial mucous 
membrane, prior to the pouring out of secretion into the lumina of 
the tubes, and in the paroxysm of bronchial asthma as a result of 
constriction of the bronchioles. The hruit de drapeau is a dry rale 
which is audible in certain cases of fibrinous bronchitis, and which 
is produced by the flapping back and forth of a fragment of ad- 
herent exudate or detached mucosa during inspiration and expira- 
tion. Sonorous rales are generated in the trachea in the presence 
of extreme compression of this tube by aneurysm, mediastinal 
tumor, or enlarged mediastinal glands, as well as in cicatricial 
stenosis of this tube. Similar rales occasionally arise in the larynx 
as a result of laryngeal diphtheria and in edema of the glottis. 

Moist rales, produced by the passage of air through serum, mucus, 
pus, or blood in the larger bronchi, or by separation of the walls 
of the terminal bronchioles and alveoli, which have become adherent 
as a result of the presence of tenacious exudate, comprise the 
crepitant rale, the siibcrepitant rale, the mucous rale, and the 
gurgling rale. 

Crepitant Rale. — The crepitant rale is produced by the separa- 
tion of the walls of the alveoli, which have become glued together 
by tenacious secretion during the expiratory recession of the 
lung. Hence, the rale is audible toAvard the termination of 
inspiration. 

The crepitant rale is the finest of all rales. Its quality has been 
compared by Laennec to the series of sharp cracklings which 
ensue upon throwing a pinch of salt upon a heated stove. Wil- 
liams compares the quality of the rale to the sound which is pro- 
duced upon rolling a lock of hair between the thumb and finger 
when held near the ear. Both comparisons are inexact, as mois- 
ture is an essential element in the production of the crepitant rale. 
The quality of the rale is aptly imitated upon moistening the tips 
of the thumb and forefinger, pressing them together, and sepa- 
rating them while the hand is held near the ear. The quality of 
the crepitant rale is readily confused with the pleural friction 



AUSCULTATION OF RESPIRATORY ORGANS 163 

sound, Avhen the latter possesses a minor intensity. The differ- 
ential points between the two sounds are considered in connection 
with the pleural friction sound in a subsequent paragraph. 

The crepitant rale is not infrequently audible upon ausculta- 
tion of the pulmonary bases in the normal subject who has passed 
a night breathing tranquilly in the dorsal decubitus. In this 
instance, however, a few deep inspirations serve to fully inflate 
the alveoli and to abolish the rale in this area. As this rale is 
dependent upon a wet lung for its production, it is natural that 
in the diseases in which it is present it is encountered over the 
bases in the majority of cases. In all cases in which crepitant 
rales are encountered over the apices of the lungs, the prognostic 
significance is grave; and if the rales are localized in this area to 
the exclusion of other portions of the lungs, it is very suggestive 
of phthisis as the underlying lesion. 

The crepitant rale is detected during the first stage of fibrinous 
pneumonia, constituting the crepitus indux of this disease. It is 
also audible over the bases of the lungs in the presence of inflam- 
mation of the mucous membrane of the terminal bronchioles and 
pulmonary alveoli in catarrhal pneumonia or capillary bronchitis ; 
and it is audible in the same regions in the presence of pulmonary 
edema, hemorrhagic infarction of the lung and in partial atelecta- 
sis. During the evolution of chronic ulcerative phthisis, and with 
less constancy in the stage of incomplete consolidation in fibrinous 
pneumonia, there is occasionally audible a fine, high-pitched crepi- 
tant rale, the mucous click. As in the case of all crepitant rales, 
the mucous click is elicited toward the completion of inspiration, 
when the inspired air has attained the ultimate ramifications of the 
bronchial system. 

Subcrepitant Rale. — The subcrepitant rale is a moist rale, a 
trifle coarser in quality than is the crepitant rale. It is produced 
by separation of the walls of the terminal bronchioles which have 
become adherent as a result of a coating of tenacious secretion 
or exudate; hence, it is audible during both inspiration and ex- 
piration. The subcrepitant rale occurs during the period of 
resolution of fibrinous pneumonia, in which disease it consti- 
tutes the crepitus redux; during thfe evolution of acute and chronic 
catarrhal bronchitis ; and in the presence of bronchial inflammation 
in catarrhal pneumonia, pulmonary infarction, and pulmonary 
edema. 

Mucous Rale. — Mucous rales are generated in the larger 
bronchi and in pulmonary cavities. They are audible during in- 



164 PHYSICAL DIAGNOSIS 

■ » 

spiration and expiration; and in quality they present a series of 
bubbling sounds, analogous to that which is produced by a fluid 
undergoing rapid fermentation, or the passage of bubbles of air 
through liquid contained in a container. Their intensity depends 
upon the quantity of fluid secretion which is present, upon the 
size of the bronchus or cavity in which they are produced, upon 
the energy of the respiratory movements, and upon the location 
of their site of production with reference to the thoracic surface. 
Mucous rales are most frequently encountered in the evolution of 
chronic ulcerative phthisis; less frequently in the presence of 
acute and chronic catarrhal bronchitis, and in the later stages 
of the paroxysm of bronchial asthma. 

Gurgling rales are mucous rales which are generated in the 
presence of a pulmonary cavity containing fluid, and with a free 
bronchial communication, which is situated below the level of the 
fluid. The rales are manifested by a series of gurgling, bubbling 
sounds which make their appearance toward the completion of 
inspiration, or merely upon change of posture of the patient. They 
are due to the passage of the inspired air through the fluid con- 
tained in the excavation, and are to be encountered during the 
advanced stages of chronic ulcerative phthisis associated with 
cavitation. 

As moist rales depend upon moisture of the lung for their pro- 
duction, their characteristics are readily influenced by the depth 
of the respiratory movements and by the act of coughing, factors 
which cause shifting of the fluid elements which call the rales into 
being. Following a particularly deep inspiration or a violent fit 
of coughing, it is not infrequent for moist rales to disappear tran- 
siently, only to reappear with the further accumulation of the 
pulmonary secretions. 

In the interpretation of rales the examiner should take into 
consideration the number, the size, the uniformity, the time of 
appearance, the intensity, and the quality of the rales, and whether 
or not they are consonating. 

The numher of moist rales which may be encountered over the 
thorax is variable in different instances. In one case there may be 
only a few rales, well circumscribed to one region of the thorax, and 
which are only brought out upon deep inspiration. If these dis- 
crete rales appear at the termination of inspiration over the bases 
posteriorly, they frequently disappear after a few inspirations. In 
this event they are merely crepitant rales which are generated by 
the full inflation of alveoli which have remained closed during 



AUSCULTATIOX OF RESPIRATORY ORGANS 165 

tranquil respiration, and are devoid of patliologic significance. A 
limited number of moist rales, enconntered over the apical portion 
of the thorax, on the contrary, is of grave prognostic significance, 
if they are persistent and are enconntered in the same area upon 
consecutive examinations. Circumscribed moist rales in this region 
are very suggestive of phthisis ; but Rosenbach has directed atten- 
tion to the extreme importance of not mistaking muscular sounds 
in this region for moist rales, particularly in subjects with power- 
fully developed pectoral muscles. 

Again, as in the case of acute and chronic catarrhal bronchitis 
and bronchial asthma, moist rales are distributed universally over 
both sides of the thorax, and are frequently in the latter disease 
of such intensity as to be audible without the aid of the stethoscope. 

The number of the rales is largely dependent upon the amount 
of the pathologic secretion which is present in the bronchial system, 
upon the energj- of the respiratory movements, and upon the site 
of the causative lesion with reference to the thoracic surface. When 
the bronchial secretions are unduly abundant and when the respira- 
tory action is very pronounced, if the lesion is deeply seated in the 
central portion of the lung, there will be a minimal number of 
rales demonstrable on account of the interference with their con- 
duction which is offered by the intervening areas of aerated pul- 
monary tissue. 

It occasionally happens that in a given case moist rales are 
so abundant that the character of the respiratory sounds are de- 
termined with difficulty, as the quality of the respiratory murmur 
is effectually masked by the predominance of the rales. In such 
event Lasegue recommends auscultation of the respiratory murmur 
immediately following vigorous coughing efforts upon the part of 
the patient, at which time the rales are temporarily in abeyance 
and the quality of the respiratory murmur may be studied. 

The size of rales is dependent upon the character of the bronchial 
secretions, the energy of the respiratory movements, and the site 
of the lesions with reference to the thoracic wall. In respect to 
their size, rales are divided into large rales, medium rales, and 
small rales. Large and medium rales are only encountered in the 
presence of fluid secretions in the lumina of the larger bronchi, 
while small rales are engendered by the presence of fluid in the 
bronchi of smaller caliber. In the ease of the large and medium- 
sized mucous rales, the intensity of the rales is in direct proportion 
to the energy of the respiratory movements and the proximity of 
the bronchus in question to the thoracic wall. 



166 PHYSICAL DIAGNOSIS 

■ * 

The uniformity of the rales which are encountered should be 
studied in every case in which moist rales are encountered. In this 
manner the student determines whether he is dealing with only one 
type of rale or with various types of rales, and from this informa- 
tion he deduces conclusions as to the portion of the bronchopul- 
monary system which is at fault. Even in the case of rales of the 
same character it is occasionally possible to detect differences in 
the quality and pitch of the rales. Thus, Laennec held that the 
crepitant rale of lobar pneumonia is uniformly more intense and of 
higher pitch than is the crepitant rale of pulmonary edema. 

The time of appearance of rales with reference to the events of 
the respiratory cycle is of aid in determining the character of 
rale with which the examiner is confronted, and serves as a basis 
for conclusions as to the site of the lesion of the bronchial system. 

Thus, the crepitant rale and the great majority of gurgling rales 
become apparent toward the completion of inspiration ; whereas the 
subcrepitant rale is demonstrable during both inspiration and ex- 
piration. Similarly the mucous rale generated in the larger 
bronchial tubes is audible during both phases of the respiratory 
cycle. The study of the time of appearance of rales should be 
abetted by the careful study of the quality of the rales in question. 

The intensity of rales depends upon the site of their production, 
the number of the rales, the size of the rales, and the state of the 
superimposed pulmonary parenchyma. Rales which are developed 
in the superficial bronchi are naturally more intense than are rales 
developing in bronchi of the central portions of the lungs. How- 
ever, the intensity of rales developing in the depths of the lungs is 
influenced by the state of the pulmonary parenchyma which is 
superjacent to these bronchial tubes, and as this is consolidated, 
compressed, cr excavated by phthisis, they assume an undue in- 
tensity and special qualities which will be described in a subsequent 
paragraph. When rales are very abundant and universally dis- 
tributed throughout the lungs, their intensity is augmented by their 
number alone, not infrequently to the extent that they are audible 
without the aid of the stethoscope or, indeed, at some distance from 
the patient. The size of the rale exerts a perceptible influence upon 
its intensity. The large and medium rales of the larger bronchi 
possess a greater intensity than do the small rales which are gener- 
ated in the smaller bronchial tubes. 

The quality of the moist rale is more difficult to seize and to 
define than in the case of dry rales. However, it is upon this 
difference in quality between dry and moist rales that the examiner 



AUSCULTATION OF RESPIRATORY ORGANS 167 

bases his conclusions as to whether he is dealing with a dry or 
with a wet lung. The bubbling quality of gurgling rales is readily 
appreciated and the incidence of the crepitant and subcrepitant 
rale at different periods of the respiratory cycle serves as a check in 
some measure upon these rales. 

Moreover, when moist rales are generated in pulmonary tissue 
which is in close proximity to pulmonary excavations, or not in- 
frequently even when the stomach or colon is excessively distended, 
the rales take on a musical quality which is closely akin to the 
quality of the consonating rales of Skcda. 

Consonating moist rales possess the musical quality to a marked 
degree ; and, as either pulmonary excavation with bronchial commu- 
nication or pulmonary relaxation and collapse, furnish excellent 
conducting media, these rales are transmitted to the surface of the 
thorax with undue intensity. These rales are attended by bronchial 
breathing, exaggeration of vocal fremitus and vocal resonance, 
and by the amphoric percussion sound. 

THE METALLIC TINKLE (GUTTA CADENS; FALLING- 
DROP SOUND) 

During auscultation of the thorax which is the seat of liydro- 
hemo- or pyo-pneumothorax, and with less constancy during 
auscultation over a large pulmonary cavity which contains fluid, 
a sound is occasionally audible during inspiration and expiration 
which resembles that which is produced by drops of water falling 
from a height upon the surface of water contained in a cistern. 
The sound has a hollow, echoing, metallic quality ; it is most 
frequently present during inspiration, though occasionally heard 
during expiration as well; and it is frequently brought out by 
changes of posture, speaking, coughing, or by jarring or shaking 
the subject. 

The physical genesis of the falling-drop sound is obscure, and 
several theories have been evolved in the attempt to explain the 
mode of production of the sound in the various pathologic cases 
in which it has been encountered. Laennec originally attributed 
the sound to the dripping of fluid from the retracted inferior 
border of the lung to the surface of an accumulation of fluid 
occupying the lower portion of the pleural cavity. Baas opposed 
this theory, asserting that droplets of fluid which are formed upon 
the superior walls of a cavity have a tendency to glide along the 
walls of the cavity, instead of falling abruptly from these supe- 



168 PHYSICAL DIAGNOSIS 

■ » 

nor regions. Leichtenstern, however, encountered a very pure 
falling-drop sound in a case of pyo-pneumothorax, wliicli was only 
demonstrable when the patient passed from the dorsal decubitus 
to the sitting' posture. Upon autopsy the case .presented villosi- 
ties of the pleural surface, which were immersed in the fluid with 
the patient in the dorsal decubitus, and which dripped fluid when 
the patient was placed in the upright posture. 

Another theory of the mode of production of the metallic tinkle 
is the assumption of the bursting of bubbles which are formed 
upon the surface of an accumulation of fluid in the pleural cavity. 
Force is lent to this explanation in certain cases by the fact that 
the sound is elicited immediately following the succussion sound 
upon jarring the subject. 

Debove and Tremolieres find a striking similarity between the 
quality of the falling-drop sound and that of the Hippocratic 
succussion sound when the latter is elicited by gentle agitation of 
the patient. These authors believe that the metallic tinkle is due 
neither to the dripping of fluid, from the retracted borders of the 
lung nor to the bursting of bubbles upon the surface of the pleu- 
ral fluid ; but that it is due to the generation of a light wave upon 
the surface of the fluid enclosed in the pleural cavity, the latter 
acting as a resonating chamber for the slight sound which is so 
generated. They hold that the rhythmical diaphragmatic move- 
ments are alone sufficient to call into being the causative waves 
in the intrapleural fluid. 

It has also been asserted that the metallic tinkle is only gener- 
ated in connection with accumulations of fluid in the pleural 
cavity when there is a patent bronchial communication with the 
pneumothorax; and that the sound is to be attributed to the 
bursting of a bubble which has formed at the orifice of the 
bronchopulmonary fistula at the moment of full inspiration. 

HIPPOCRATIC SUCCUSSION; (SPLASHING SOUND) 

In the presence of hydro- liemo- or pyo-pneumothorax, when 
the upper portion of the trunk is abruptly jarred or shaken, the 
ear of the examiner meanwhile being applied closely to the 
thoracic wall, a distinct sound of splashing is frequently audible, 
which is analogous to that which is produced by suddenly moving 
a partially filled cask. The succussion sound is a reliable sign of 
the presence of air and fluid in the pleural cavity; hence it is 
absent in pleurisy with effusion. The succussion sound arising 



AUSCULTATION OF RESPIRATORY ORGANS 169 

within the pleural cavity should not be confused with similar 
splashing sounds which are generated within a dilated stomach. 
While in the case of large pulmonary cavities containing air 
and fluid the physical conditions are ideal for the generation of 
Hippocratic succussion, it is rare that these excavations are so 
favorably situated with reference to the thoracic surface that 
succussion sounds are appreciable over them. 

THE PLEURAL FRICTION SOUND 

In the normal subject, as a result of the smooth, polished sur- 
face of the visceral and the parietal pleura, moistened by a moderate 
amount of serous fluid, these membranes glide noiselessly over each 




Fig. 68. — Usual site of pleural friction sound. 



other during the respiratory movements. During inflammation of 
the membrane, however, and as a result of the excessive extraction 
of the body fluids which accompanies prolonged diarrhea and 
profuse hemorrhage, as well as in the presence of miliary tuber- 
culosis and carcinomatous infiltration of the pleura, there is 
generated a pleural friction sound, which is audible upon auscul- 



170 PHYSICAL DIAGNOSIS 

■ * 

tation of the surface of the thorax. Jiirgensen and Waldenburg 
would make a distinction between pleuritic friction, which is due 
to inflammatory processes of the pleural membrane, and pleural 
friction, which occurs with roughening of the membrane by the 
nodules of acute miliary tuberculosis, carcinomatous infiltration 
of the pleura, and osseous excrescences of the ribs, which they do 
not regard as essentially inflammatory in origin. As the pleural 
membrane is extremely prone to undergo inflammatory changes 
in the presence of even minor grades of irritation, it is not im- 
probable that all of these conditions are attended by pleuritis of 
varying intensity. 

The pleural friction sound presents extensive variations in its 
quality and intensity. In cases of slight pleural involvement it 
possesses a very light, grazing sound, analagous to that which is 
produced when the finger lightly strokes a silken fabric. In the 
presence of more severe pleural inflammation, the sound is very 
similar to that which is produced upon walking upon dry, new- 
fallen snow, or to the creaking of a new leathern saddle, which has 
given rise to the name of the hriiit de cuir neuf. 

While in many instances the pleural friction sound is a continu- 
ous sound, appreciated throughout the greater duration of the res- 
piratory phase in which it is audible, in other cases it presents one 
or more interruptions, as if the roughened pleura were successively 
surmounting obstacles during the excursion of the lung. 

The intensity of the pleural friction sound is in direct proportion 
to the intensity of the respiratory movements, to the extent of 
the pleura which is diseased, and to the severity of the inflam- 
matory process. In cases of very limited pleural involvement the 
sound is very faint, requiring a trained ear for its detection. In 
other cases the sound is so intense as to be audible without the aid 
of the stethoscope, and is accompanied by distinct pleural friction 
fremitus unon palpation. Voluntary acceleration of the respira- 
tory rate and increased depth of inspiration serve to increase the 
intensity of the sound. The intensity of the friction sound may be 
artificially increased by the exercise of pressure in the intercostal 
spaces of the area in which it is encountered. Occasionally the 
friction sound is transitorily suppressed after several deep in- 
spirations, probably as the result of smoothing out of the rugosities 
of the membrane, as the sound reappears upon resuming respira- 
tion after its temporary suspension. 

Pleural friction is most frequently audible during inspiration; 
with less frequency during inspiration and expiration; and very 
rarely indeed is it audible during expiration alone. 



AUSCULTATION OF RESPIRATORY ORGANS 171 

The localization of pleural friction naturally corresponds with 
the distribution of the inflammatory disease of the pleura. It is 
encountered most frequently in the lower axillary and infra- 
axillary regions, where it is most frequently observed along an 
ascending and descending plane. When, in these areas, the friction 
seems to occur in a transverse direction, it is suggestive of the limi- 
tation of the A^ertical excursion of the lung by pleural adhesions. 
Pleural friction is not frequently encountered over the apical 
portions of the lungs, as these regions enjoy only a limited range 
of mobility during the respiratory movements ; but when pleural 
friction is encountered here, it is very suggestive of tuberculous 
lesions which are complicated by a fibrinous pleurisy. 

The duration and persistence of pleural friction are subject to 
wide variations. During the course of serofibrinous pleurisy the 
friction sound appears prior to the development of the effusion ; it 
disappears with the advent of the effusion ; and not infrequently it 
again becomes audible with resorption of the effusion, occasionally 
to persist thereafter during the entire life of the individual. In 
cases of abortive acute fibrinous pleurisy, the sound may be present 
upon one examination, to disappear immediately thereafter. When 
pleural friction develops in the supra- and infraclavicular regions 
in connection with chronic ulcerative phthisis, the sounds com- 
monly persist throughout the course of the disease. 

As pleural inflammation very frequently complicates diseases of 
the lungs which are attended by rales, it is natural that pleural 
friction and rales of various types are frequently present in the 
same subject; and in many instances their differential diagnosis is 
attended by some difficulty. In this connection it is to be recalled 
that upon exerting pressure with the stethoscope in the intercostal 
spaces the intensity of pleural friction is commonly accentuated, 
while this maneuver is without influence on the intensity of rales. 
Moreover, rales are more continuous than is the case with pleural 
friction; rales change in character or transiently disappear after 
coughing attacks; and compression of the thorax in the presence 
of pleural disease is acutely painful, while similar compression of 
the chest in pulmonary disease unattended by pleurisy is provoca- 
tive of only slight pain if indeed there is any pain. 

THE LUNG-FISTULA SOUND 

In the presence of hydropneumothorax with a bronchial com- 
munication opening into the pleural cavity below the level of the 
fluid, Riegel first described the lung-fistula sound. The sound is 



172 PHYSICAL DIAGNOSIS 

■ * 

manifested by a series of bubbling, gurgling sounds upon auscul- 
tation of the diseased side under suitable conditions. When, 
under proper maneuvers, the aerial content of the pleural cavity 
is rarefied in the region superjacent to the fluid, during inspi- 
ration a portion of the inspired air enters the cavity below the 
level of the fluid, and in ascending to the surface, engenders 
bubbles which produce the gurgling, lung-fistula sound. Unver- 
richt noted the sound following partial aspiration of a hydro- 
pneumothorax, the superjacent air in this instance being rarefied 
by the evacuation of the fluid. 

In Eiegel's case the sound appeared without aspiration of the 
fluid. In this case, as soon as the patient was placed in the sitting 
posture, he expectorated a considerable quantity of the pleural 
fluid, which passed by way of the bronchial fistula. Following 
this partial evacuation of the fluid, the balance between the 
aerial pressure in the bronchial system and in the pleural cavity 
was disturbed; and during inspiration a portion of the inspired 
air entered the pleural cavity below the level of the fluid, and in 
its ascent through this latter engendered the lung-fistula sound. 

The sound may be elicited without aspiration or expectoration 
of the fluid by the procedure of Meezenbrock. This author has 
the patient assume the lateral decubitus, lying upon the side of 
the disease. He then seizes the dependent side of the thorax 
between the hands, and by compression evacuates a portion of 
the pleural fluid into the air passages through the fistulous open- 
ing. When the patient assumes the sitting posture and the pres- 
sure is gradually released from the diseased side, the air 
penetrates into the pleural cavity through the fistulous opening 
and produces the lung-fistula sound. 



CHAPTER VI 
THORACOMETRY, CYRTOMETRY, AND THORACENTESIS 

Thoracometry, or mensuration of the thorax, is employed to 
determine at consecutive examinations variations in the total 
circumference of the chest ; to determine the presence of unilat- 
eral bulging or retraction of the thorax ; and to estimate the total 
expansion of the chest. 

In the determination of the total expansion of the thorax the 
difference between the circumference of the chest during com- 
plete expiration and during complete inspiration is taken, the 
difference between the two measurements taken at the level of the 
nipples indicating the total expansion or vital capacity of the 
thorax. A total expansion of three to four inches obtains in the 
average adult male subject, though slight discrepancies below 
or above these figures are not to be considered pathologic. 

In the determination of unilateral variations in the size of the 
two sides of the thorax it is customary to measure from the mid- 
spinal line to the midsternal line upon each side and note any 
discrepancy in the two measurements. Allowance must be made 
for the fact that the right half of the thorax is normally slightly 
larger than is the left half. In making all measurements of the 
thorax the common tape measure is the appliance of choice, save 
in calculating the various diameters of the thorax, w^hen a spe- 
cially devised calipers is employed. • 

In determining the anteroposterior and transverse diameters 
of the thorax the calipers is used. In the estimation of the antero- 
posterior diameter one point of the instrument is placed over the 
midspinal line and the other OA^er the midsternal line, and the 
measurement is read off on the scale of the instrument. The 
transverse diameter of the thorax is determined by applying a 
point of the calipers to each midaxillary line and reading the di- 
ameter as indicated upon the scale. 

Cyrtometry, the determination of the curves of the surface of 
the thorax, is practiced by applying the cyrtometer accurately to 
the surface of the thorax. The cyrtometer consists of two pieces 
of flexible metal connected at one end by a hinge. In practicing 
cyrtometry of the thorax the hinge is placed over the midspinal 

173 



174 PHYSICAL DIAGNOSIS 

■ » 

line, and the blades of the instrument are accurately moulded to 
the surface of the thorax. Upon removal of the instrument a 
tracing may be made, showing the shape of a cross-section of the 
thorax, and revealing any unilateral variations of the two sides 
of the chest. 

Thoracentesis, the aspiration of fluid from the pleural cavity, 
is usually preceded in practice by exploratory puncture of the 
pleural sac. The latter maneuver is frequently performed in 
order to establish the diagnosis of fluid in the pleural cavity and 



Fig. 69. — Potain's aspirator. 

for the purpose of securing a specimen of fluid for microscopic 
and bacteriologic examination. 

In the performance of the slight operation of exploratory 
puncture of the pleura, a large hypodermic syringe equipped with 
a heavy needle should be employed. Aseptic precautions should 
be strictly observed throughout the procedure in order to avoid 
the introduction of infective organisms into the pleural cavity, 
thus converting a serous into a purulent effusion. The pleural 
cavity may be entered in the scapular line in the seventh inter- 
costal space or in the midaxillary line in the sixth interspace with 



THORACOMETRY, CYRTOMETRY, AND THORACENTESIS 175 

equally satisfactory results. In securing a specimen by explora- 
tory puncture, only a few cubic centimeters should be withdrawn, 
which should immediately be transferred to a sterile test tube 
for microscopic and bacteriologic study. 

As exploratory puncture is performed for purposes of diag- 
nosis, so aspiration is practiced for therapeutic purposes. In the 
practice of aspiration a large needle, connected by rubber tubing 
with a closed jar from which the air has been exhausted, is in- 
serted into the pleural cavity beneath the level of the fluid and 
the fluid is gradually drawn off into the vacuum. In the inser- 
tion of the needle, the intercostal artery, which courses along the 
lower border of the rib, should be avoided. 

During aspiration it is not advisable to withdraw entirely the 
fluid which occupies the pleural cavity at a single sitting. More- 
over, if at any time during the aspiration the patient complains 
of distress, the procedure should be immediately suspended. 



CHAPTER VII 
RADIOGRAPHIC DIAGNOSIS 

By Dudley E. Mackey, B.S., M.D., New York. 

The purpose of this chapter upon radiographic diagnosis is to 
treat only of the x-ray with reference to its use as a link in the 
chain of clinical data, as a means of examination which will aid 
the student of medicine or the physician in rendering a diag- 
nosis. The principal aim throughout will be to present as nearly 
as possible in the space employed definite facts which are used 
and brought out in radiographic examination of various regions 
of the human body. Obviously it is impossible in this place to 
deal with technic and the use of apparatus. 

Remarkable progress has been made in the advance of radio- 
graphic diagnosis since its introduction in 1895, and this has 
been especially made so by the invention of the Coolidge tube, 
which has given such good service in the recent war. 

In this chapter the subject matter will embrace radiographic 
diagnosis of bones and joints; the head with the accessory sinuses, 
mastoids, and teeth; the thorax, gastrointestinal tract, and urin- 
ary tract. 

BONES AND JOINTS 

In dealing with the bones and joints, radiography is of value 
in enabling us to determine whether a fracture is present, the 
position and number of the broken parts, the best method of cor- 
rection, and serves as a means of observation after a retentive 
dressing has been applied. 

Radiographically, fractures are classed as simple and as com- 
minuted. The simple fracture may be further subdivided ac- 
cording to the direction of the fracture. Fractures may be 
studied with the x-ray either fluoroscopically or by the plate 
method. For a permanent record the plate method is preferable. 
If the plate method is employed, two views of the part examined 
should always be required, while in the examination of joints a 
diagnosis should not be attempted without the use of stereoscopic 
plates. The latter method of examination will sometimes bring 

176 



RADIOGRAPHIC DIAGNOSIS 



177 




Fig. 70. — Compound-comminuted fractures of phalanges and metacarpal of hand. 



178 



PHYSICAL DIAGNOSIS 



out fine, hair-line fractures which would be overlooked on a 
flat plate. 

In the examination of a fracture, before rendering a diagnosis, 
it is necessary to observe the area involved, the shaft, tissue sur- 
rounding the fracture, the bone or bones involved, its condition, 
displacement, position, type of fracture, and number of frag- 
ments. If the case is one of long standing with bone changes, 
search should be made for sequestra, giving their size and posi- 
tion. Observation should also be made as to whether the joint 
surfaces are invaded by the fracture. Under no circumstances 




Fig. 71. — Stellate fracture of great trochanter of femur. 



should the splints or bandages be removed during radiography 
without the consent of the attending surgeon. 

The student who would become proficient in the interpreta- 
tion of plates must gain a thorough knowledge of the bony skel- 
eton, together with the study of normal radiography. It is essen- 
tial that he should study the normal adult subject. The study 
of the ossification of the epiphyseal lines radiographically is very 
important, and any standard work upon anatomy will give this 
information. Comparative plates of both right and left will some- 
times differentiate between a fracture and an epiphyseal separa- 
tion in a doubtful case. 



RADIOGRAPHIC DIAGNOSIS 



179 



Fractures of the skull are in some cases very difficult to diag- 
nose, because of the presence of sutures and blood vessel mark- 
ings. The diagnostician should be very careful not to mistake 
a suture line for a fracture. Indeed, a fracture of the skull may 
not give marked evidence of the break in continuity, yet may 
cause injury to the blood vessels, nerves, and brain substance. 




-Impacted fracture of head of humerus with separation and displacement of head 



The diagnosis of fracture of the skull should not be attempted 
without the use of stereoscopic plates. AVith these for observa- 
tion, a thorough examination of the skull should be made, keeping 
ever in mind the fact that blood vessel markings and sutures have 
been mistaken for fractures. 



180 PHYSICAL DIAGNOSIS 

• » 

In dealing with suspected fractures of the skull the examiner 
should systematically examine the contours of the inner plate for 
any break in continuity. Here especially the student should 
be familiar with all the shadows and markings which appear upon 
the normal plate. The technic is very important in the correct 
reading of plates in head injuries. 




Fig. 1Z. — Depressed fracture of the skull. 

Radiographic diagrams of the spine should always be made, 
if possible, from stereoscopic plates, together with a lateral view. 
Fluoroscopic examination of the spine is of very limited value, 
except in certain cases of the cervical spine or lumbar region. A 
careful examination of each vertebra should be made before ren- 
dering a decision, keeping the normal picture ever in mind. 



RADIOGRAPHIC DIAGNOSIS 



181 




Fig. 74. — lyinear fracture of the vault. Stellate in type. 



182 



PHYSICAL DIAGNOSIS 




Fiar. 75. — T.incnr fracture nf the sK'iill invnlvinsj tlie frontal sinus. 




Fig. "Ki. — Accessory sinus. Frontals clear, ethmoids clear, and antrum cleai 



RADIOGRAPHIC DIAGNOSIS 



183 



Pathologic conditions found in the spine comprise lesions in- 
volving the bodies of the vertebrae, and lesions involving the ar- 
ticulating surfaces. Among the lesions of the articulating sur- 
faces we class arthritis, infectious and hypertrophic, and the 
beginning of tuberculosis. Lesions may have their inception in 
the articulating surface and invade the body, notably tubercu- 
losis in the second stage, neuropathic conditions, and fractures. 
We may have new growths and osteomyelitis, both of which m?y 
involve the body of the articulating surface. 




Fig. n. — Absence of frontal sinus. 



Tuberculosis is a bone-destroying process, not a bone producer. 
In tuberculosis of the spine the anterior portion of the body be- 
comes softened and gives way, becoming characteristic in ap- 
pearance, triangular in shape, with the apex anteriorly and the 
base of the triangle posteriorly, leading in time to tubercular 
kyphosis. 

Differential diagnosis between tuberculosis of the spine, frac- 
ture, neuropathic conditions, and bone lesions: 



184 



PHYSICAL DIAGNOSIS 





SHAPE 


DISPLACEMENT 


BONE PRODUCTION 


Tuberculosis 
Fracture 

Neuropathic 
New Growth 


Angulation 
Angulation 
Angulation 
None 


Anteroposterior 

Lateral 

Lateral 

None 


None 

New bone 

New bone 

Bony detritus. Narrowing of 

body, production depending on 

type 



THE LONG BONES 

Obviously my discussion of the pathologic lesions will be brief. 
Radio graphically two changes take place ; namely, bone produc- 




Fig. 78. — Large frontal sinus. Right antrum cloudy. 



tion, and bone destruction. Also it is necessary to determine in 
each case whether we are dealing with a malignant or with a 
benign condition. 

To aid the student in diagnosis, we will classify bone lesions 
as follows: origin, bone production, cortex, and invasion. In 
the first place, does the growth begin in the medullary canal, in 
the cortex, or in the periosteum? In the second place, are we 
dealing with bone production or with bone destruction? Thirdly, 



RADIOGRAPHIC DIAGNOSIS 



185 



are there evidences of infiltration? By the use of the following 
classification, the student will be enabled to study and analyze 
the radiographic findings : 




Fig. 79. — Frontal sinus clear, ethmoids clear, both antra cloudy. 



LESION 


ORIGIN 


BONE PRODUCTION 


INFILTRATION 


TYPE 


Exostosis 


Shaft 


Present 


Absent 


Benign 


Osteoma 


Cortex 


Present 


Absent 


Benign 


Osteosarcoma 


Cortex 


Present, "with 
destruction 


Present 


Malignant 


Periosteal 


Periosteum 


Present in soft 


Present 


Malignant 


sarcoma 




tissues 






Giant cell 


MeduUa, 


Absent 


Expected 


Benign 


sarcoma 










Cyst 


Medulla 
Cortex 


Absent 


Expected 


Benign 


Ossifying 


Periosteum, 


Present 


Absent 


Benign 


hematoma 


hemorrhage 








Periostitis 


Periosteum, 
inflammatory, 
luetic 


Present 


Absent 


Benign 


Osteomyelitis 


Shaft 


Present, with 
bone destruc- 
tion 


Present 


Benign 


Carcinoma 


Medulla, near 
nutrient 
artery 


Absent 


Present 


Malignant 




Fig. 80. — Absence of one frontal sinus. Ethmoids clear, both antra cloudy. 



ARTHRITIS 

In arthritis we have to deal with three structures ; namely, syno- 
vial fluid, synovial membrane, and cartilage. The diagnosis, there- 
fore, must be made upon the changes encountered in the above 
structures. Kadiographically, we may classify arthritis as follows: 











SYNOVIAL 


DESTRUCTION OF 


ARTHRITIS 


AGE 


FLUID 


BONE 


MEMBRANE 


CARTILAGE 


Polyarthritis 


Any 


Increased 


Negative 


Swollen 


Absent 


Infectious, 


Adult 


Increased 


Negative 


Swollen 


Absent 


first stage 












Infectious, 


Adult 


Absorbed 


Atrophy 


Swelling 


Absent 


second stage 








decreased 




Infectious, 


Adult 


None 


Atrophy 


None 


Eroded 


tliird stage 












Atrophic 


Early, 
middle 


Absent 


Atrophy 


None 


Absorption 


Hypertrophic 


Middle, 
old age 


Absent 


None 


None 


Present with 
exostosis 


Joint tuber- 




Absent 


Hazy 


Thickened 


None 




culosis 












Tuberculosis 
subsides 




Absent 


clear but 
eroded 


None 


Present 




Syphilitic 




Present 


Periostitis 


Thickened 


None 




Charcot 




Present 


Destruction 


Thickened 


Destruction, 
new bone 






Present 


Change and 


None 


Ankylosis patel- 












exostosis 




lar cartilage 



RADIOGRAPHIC DIAGNOSIS 



187 



THE HEAD 

The radiographic study of the head should be made from stereo- 
scopic plates, as the complexity of the shadows is such that a 
clear reading of the plates cannot be made from flat plates. 

One of the most difficult and one of the most frequently over- 
looked conditions is the diagnosis of fracture of the skull. As 
stated, blood vessel markings and sutures have frequently been 
mistaken for fracture lines. 




Fig. 81. — Sella turcica well defined — normal sphenoidal sinus clear. 



Fractures of the skull are generally of two classes; namely, 
linear, and depressed. The depressed fracture, which is caused 
by a blow from without, may affect the inner table only, and it 
is most important that this type of fracture should be detected. 
Without stereoscopic plates it is not apt to be clearly defined. 

The study of the mastoid area is of the utmost importance, and re- 
quires for proficiency an extensive study in the interpretation of 
shadows. The size of the cells, which do not appear before the 
age of five years, has an important bearing upon the prognosis. 
Both right and left mastoids should be made for comparison, as 



188 



PHYSICAL DIAGNOSIS 



they are generally similar in structure. It is very difficult for 
the student to acquire a knowledge of mastoid conditions from 
printed matter, as the observation of a large number of plates 
and a study of the operative findings is necessary for the attain- 
ment of proficiency in this field of work. The same is equally 
true of the accessory sinuses, since when pathology is present, the 
accuracy of the diagnosis depends entirely upon the technic of 
making the plate and the comparison with the normal shadow. 




Fig. 82. — Mastoid cells normal. lyarge type. 

The technic should be such that the frontal sinus, ethmoids, 
sphenoid sinus and antrum will be clearly defined. 

We will not dwell upon dental diagnosis, even though it is of 
the utmost importance, as the student will find available several 
good works upon dental diagnosis. Several illustrations showing 
common pathologic dental findings are, however, hereto appended. 



THE THORAX 

The diagnosis of intrathoracic conditions should never be at- 
tempted from flat plates. The study of the normal picture is very 



RADIOGRAPHIC DIAGNOSIS 



189 



necessary, as the appearance of the lung changes as the subject 
advances in age and also as the result of disease. 

The air vesicles of the normal lung cast no shadows; but the 
lymphatics cast shadows which are more dense at the hilus and 
which decrease in distinctness toward the periphery. It is the 
various gradations in density from the normal to the pathologic 




Fig. 83.— Apical abscess. 



lung which enable us to read the diagnosis into the plate. In 
a large number of cases the Avrong opinion has been given in the 
reading of plates, especially in the case of pulmonary tuberculo- 
sis, owing to the lack of a clear interpretation of the shadow 
densities. This knowledge is only to be obtained through the 
reading of numerous plates under proficient guidance. There are 
numerous shadows present upon the plate which have no relation 



190 



PHYSICAL DIAGNOSIS 




Fig. 84. — Old unextracted root. 




Fig. 85. — Unerupted teeth. E^arly life. 



RADIOGRAPHIC DIAGNOSIS 191 

to the disease. Blood vessels, bronchi, calcareous areas, all are 
found in normal pulmonary tissue, and should not be mistaken for 
pathology. The breast of the female subject, the pectoral mus- 
cles, and the scapulae should be carefully noted in each case. Sim- 
ilarly, the hilus of the lung and the trachea cast shadows, which 
should be borne in mind when interpreting any plate. 

The Diaphragm. — Radioscopy affords the most reliable means 
of studying limitations and variations in the movements of the 
diaphragm. Upon fluoroscopic examination, variations in the 
movements, position, and general outline of this important mus- 
cle may be noted. Unilateral limitation of the mobility of the dia- 




Unerupted molar. Adult. 



phragm is often significant of incipient phthisis (Williams' sign). 
However, similar limitation of movement of the muscle may be 
caused hy increased subphrenic pressure or by the traction of 
pleural adhesions. 

The general outline of the diaphragm is altered in diaphrag- 
matic paralysis and in the presence of diaphragmatic hernia. In 
the case of the latter affection straining or coughing will increase 
the herniation of the sac contents. 

Pulmonary Tuberculosis. — In tuberculosis of the lungs radi- 
oscopy of the thorax reveals multiple patches of mottling in the 
area involved, a diminution in the transparency of the pulmonary 
tissues, w^hich is not, however, as dense or as sharply circum- 



192 PHYSICAL DIAGNOSIS 

scribed as is the shadow cast in lobar pneumonia. On the con- 
trary, in pulmonary tuberculosis there are multiple areas of 
impaired transparency, often superimposed, and frequently not 
exceeding one-fourth inch in diameter. In incipient tuberculosis 




Fig. 87. — Impacted molar. 



the mottling is usually circumscribed to the apical or axillary 
regions, the inferior portions of the lungs remaining clear at this 
staare of the disease. 



RADIOGRAPHIC DIAGNOSIS 



193 




Fig. 88. — Unerupted canine. 



194 



I^HYSICAL DiAGNOSIS 



Partially healed tuberculous lesions associated with calcareous 
deposit give a greater diminution of transparency and a greater 
density, producing an altogether more clear-cut picture than 
that afforded by recent or active tuberculous lesions. The peri- 
bronchial lymph glands, when involved, cast shadows which must 






. — Normal heart diagram method of estimating size by use of radiograph. 



be differentiated clinically from similar shadows due to enlarge- 
ments of these glands, which are dependent upon the acute in- 
fectious diseases or syphilis. Cavities, when empty, are repre- 
sented by transparent zones, usually surrounded by a darker zone.^ 
corresiDonding to adjacent pulmonary consolidation. 

Syphilis of the lung gives a picture closely simulating that of 



RADIOGRAPHIC DIAGNOSIS 



195 




Fig. 90. — Normal stomach — normal cap. 




Fig. 91. — Penetrating ulcer of lesser curvature. 



196 



PHYSICAL DIAGNOSIS 



pulmonary tuberculosis; so much so, indeed, in many instances 
that the course of the disease must be studied in the differential 
diagnosis. 

Abscess and gangrene of the lung yield signs of pulmonary 
excavation, the differential diagnosis from tuberculosis resting 
upon the history and clinical manifestations of the disease. 

Pneumonia. — In lobar pneumonia, during the early stage with 
imperfect consolidation, there is a diminution of the transpar- 
ency of the pulmonary tissues, usually having its inception around 




Fig. 92. — Hourglass stomach. 



the bronchi, more rarely peripherally. When consolidation is 
fully established, a dark shadow with well-defined borders is 
cast, corresponding to the lobe or lobes involved in the disease. 
The shadow is occasionally so extremely dense as to obscure the 
shadows cast by the ribs overlying the area of consolidation. 

Bronchopneumonia produces multiple small shadows, often su- 
perimposed, and distributed universally over both lungs. The 
picture closely resembles that of acute miliary tuberculosis of 
the lungs with its numerous widely disseminated areas of consol- 
idation. 



RADIOGRAPHIC DIAGNOSIS 



197 



Chronic interstitial pneumonia gives a characteristic shadow 
when radiographed. Shadows corresponding to fibrous bands of 
induration extend outward in various directions from the hilus 
of the lung toward the periphery. 

Pulmonary Neoplasms. — A large, single tumor of the lung or 
pleura is revealed by a dense shadow corresponding in extent to 
the area of distribution of the growth. Small, disseminated, 




Fig. 93. — Appendix visible. 

metastatic growths, on the contrary, give a picture which is with 
difficulty differentiated from Avell-established tuberculosis of the 
lungs. 

Pleural Thickening. — Thickening of the pleura produces a hom- 
ogeneous shadow, the density of which corresponds closely with 
the degree of thickening which is present. A small area of ex- 
cessively thickened pleura gives a picture closely simulating that 
produced by a pulmonary neoplasm. 

Pleural Effusion. — Pleural effusion produces a homogeneous 
shadow, which contrasts markedly with the transparence of the 



198 



PHYSICAL DIAGNOSIS 



opposite side of the thorax. The diaphragm upon the side of the 
disease is displaced downward and the heart and mediastinal 
structures are displaced toward the opposite side of the thorax. 
Pneumothorax. — Pneumothorax is distinguished from other in- 
trathoracic conditions by the uninterrupted transparency over 
the area involved, indicative of the absence of the pulmonary tis- 




Fig. 94. — ^Normal kidney. 



sue from this portion of the pleural cavity. In pyopneumothorax 
this zone of transparency is bordered inferiorly by the dense 
shadow cast by the purulent collection, the superior border of 
which may be observed to undulate upon forcible percussion of 
the thorax during fluoroscopy. 

Mediastinal Tumors. — In the case of tumors of the mediastinum 
the shadow of the tumor is fairly accurately reproduced and its 



RADIOGRAPHIC DIAGNOSIS 



199 



size, extent, and relation to surrounding structures may be stud- 
ied. A solitary, large tumor casts a relatively dense shadow, 
whereas multiple small, metastatic growths show multiple patches 
of impaired transparency within a fairly small space in the upper 
portion of the mediastinum. 




Fig. 95. — Injected sinus. 



The Heart. — Radioscopy affords a valuable means of investi- 
gating the size, shape, and position of the heart and pericardium. 
Upon fluoroscopic examination, which is a ready and convenient 
method of studying cardiac conditions, during forced inspira- 
tion the transverse diameter of the cardiac shadow appears to 



200 PHYSICAL DIAGNOSIS 

■ » 

diminish, to return again to its normal dimensions upon full 
expiration. Upward displacement of the diaphragm, due to in- 
creased intraabdominal pressure, causes an increase in the transverse 
shadow of the heart. Immense hypertrophy and dilatation also are 
indicated by an increase in the transverse diameter of the cardiac 
shadow, whereas unilateral hypertrophy imparts an irregular con- 
tour to the cardiac shadow. Radioscopy also reveals displace- 
ment of the heart toward the right or left by disease in the opposite 
lung or pleural sac ; displacement upward by increased subphrenic 




Fig. 96. — Calculi in bladder. 

pressure; or displacement downward from the weight of an aneu- 
rysm of the aortic arch, or the pressure of the lungs in hypertrophic 
emphysema. 

Pericarditis. — Acute fibrinous pericarditis yields no character- 
istic changes in the cardiac shadow. In serofibrinous pericarditis 
with effusion, however, the shadow cast by the precordial struc- 
tures is increased transversely, particularly toward the right, 
encroaching upon the normal transparency in the cardiohepatic 
angle of Ebstein, The shadow, however, is not as dense as that 



RADIOGRAPHIC DIAGNOSIS 



201 



produced by immense cardiac hypertrophy, and in addition, it 
is roughly triangular with the base resting upon the diaphrag- 
matic shadow, not infrequently causing downward displacement 
of the left side of this muscle. 

Aneurysm of the thoracic aorta affords a shadow in the course 
of the vessel, and shows its relation to surrounding structures 
and its relative size. 




Fig. 97. — Calculi in bladder. 

THE URINARY TRACT 

The urinary tract is worthy of due consideration radiograph- 
ically. The former methods of diagnosis are materially aided by 
the use of correct and careful examination of the bladder, ureter, 
and kidney. Even though a stone is observed upon the plate, it 
is impossible to state its exact position, especially if h^ing above 
the bladder. Here accurate and correct technic is absolutely nee- 



202 



PHYSICAL DIAGNOSIS 



essary in order to render a clear-cut diagnosis. Gystonretero- 
pyeloroentg-enography will aid materially in the diagnosis. 

Pyelography. — The injection of certain substances which are 
opaque to the rays will demonstrate the renal pelvis and calyces, 




l-''ig. 98. — Calculus after removal. 




Fig. 99. — Encapsulated empyema. Right. 

also the position of the ureters and bladder. Thorium nitrate, 
collargol, and argyrol have been used. At present we are using 
sodium iodide, which is found to be very satisfactory and non- 
irritating to the patient. It gives an excellent contrast on the 
plate. 



RADIOGRAPHIC DIAGNOSIS 



203 



THE GASTROINTESTINAL TRACT 

The examination of the gastrointestinal tract radiographically 
is to a certain extent not fully understood by the average prac- 
titioner. The technic of this examination radiographically is 
of paramount importance, provided the diagnosis is made by an 
experienced radiologist. The serial examination of the tract is 
very necessary to determine the presence or absence of pathologic 




Fig. 100. — Tuberculosis of the chest with typical drop heart. 

changes. The one or two plate method following a barium meal 
is to be condemned as a waste of the time of both physician and 
patient. 

The findings of the gastrointestinal tract which we most com- 
monly search for are gastric ulcer, duodenal ulcer, adhesions, 
gall bladder disease, stones, and malignant disease. The space 
allotted to this subject will not suffice for a discussion of the 



204 



PHYSICAL DIAGNOSIS 



different diagnostic points; but I wish to insist upon the fact that 
a thorough study of the case should be made before a diagnosis 
is rendered. 

The illustrations in this chapter it is hoped will afford the 




Fig. 101. — Tuberculosis of the lung. 



reader an adequate conception of the conditions which are best 
studied radiographically ; and the perusal of a text together with 
the observation of a large number of plates will perfect the stu- 
dent in radiographic diagnosis. 



SECTION III 

DISEASES OF THE RESPIRATORY ORGANS 

CHAPTER VIII 

DISEASES OF THE BRONCHI 

ACUTE BRONCHITIS 

Clinical Pathology. — Acute bronchitis, an acute catarrhal in- 
flammation of the mucous membrane of the medium-sized and 
larger bronchi, occurs as a primary affection, and as a compli- 
cation of many of the acute infectious diseases, notably the ex- 
anthematous fevers, influenza, typhoid fever, and malaria. 

The disease is most prevalent during the sudden changes of 
early spring and late autumn. Among predisposing causes may 
be mentioned particularly acute coryza, affecting the upper re- 
spiratory passages; and passive congestion of the lungs incident 
to regurgitant heart disease, acting upon the lower portions of 
the bronchial tree. The organism which is most frequently 
causative is the pneumococcus, alone or in conjunction with the 
staphylococcus, the colon bacillus, the micrococcus catarrhalis, 
or the bacillus typhosus. 

During the early stages of the inflammation the mucous mem- 
brane of the bronchi is swollen and red, but is dry. During the 
further evolution of the disease, however, the congested mucous 
membrane becomes bathed with secretion, mucopurulent or puru- 
lent in character, containing large numbers of desquamated epi- 
thelial cells and bacteria. 

Physical Signs. — Mild cases of acute bronchitis yield few phys- 
ical signs which are characteristic of the affection. In the more 
severe grades of bronchial inflammation physical signs are more 
in evidence, but often require a very careful examination to af- 
ford definite diagnostic data. 

Inspection in the milder cases usually reveals nothing abnor- 
mal, but in more severe cases there is moderate acceleration of 
the respirations ; while if there is a complicating or concomitant 
inflammation of the finer bronchioles (capillary bronchitis), the 

205 



206 PHYSICAL DIAGNOSIS 

■ * 

condition is attended by a considerable degree of dyspnea, and 
in the young subject, cyanosis. 

Palpation, negative in cases of moderate severity, in well- 
developed cases of acute bronchitis may reveal slight rhonchal 
fremitus distributed over both lungs. 

Percussion seldom elicits any alteration of the normal vesicular 
resonance in cases of frank acute bronchitis. Occasionally in very 
severe cases a slight impairment of resonance is evident over the 
bases posteriorly. The bases should be carefully percussed daily 
in order that a complicating bronchopneumonia may be recog- 
nized in its inception. 

Auscultation during the early stage of the disease reveals the 
presence of sibilant and sonorous rales well distributed over 
both lungs. In a later stage of the affection, after the secre- 
tion has become freely established, moist rales appear, the crep- 
itant rale predominating the clinical picture. 

Vocal resonance is not perceptibly altered. The respiratory 
murmur is harsh or puerile; but in uncomplicated acute bron- 
chitis the breath sounds are never- purely bronchial. 

Diagnosis. — The diagnosis of acute bronchitis rests upon the 
absence of physical signs other than puerile breathing and a few 
rales distributed over both sides of the thorax, coupled with cer- 
tain subjective symptoms, as an initial chill or chilliness followed 
by moderate fever, a dry hacking cough which loosens with the 
establishment of the bronchial secretions; a feeling of rawness 
and pain beneath the sternum ; and a general feeling of malaise 
and pain in the back and limbs. 

Differential Diagnosis. — In its abrupt onset the disease fre- 
quently is suggestive of lohar pneumonia; but this disease is elim- 
inated by the absence of physical signs of consolidation ; namely, 
increased vocal fremitus and resonance, flatness, and blowing, 
tubular breath sounds. Moreover, lobar pneumonia is almost 
invariably a unilateral affection, whereas acute bronchitis is bi- 
lateral in its manifestations. The constitutional toxemia and 
depression of lobar pneumonia far surpass that which attends 
acute bronchitis. 

Bronchopneumonia is usually gradual and insidious in its pri- 
mary manifestations; and, in addition to the physical signs of a 
diffuse acute bronchitis, presents multiple areas of impaired 
resonance, over which the respiratory sounds are bronchial or at 
the least are bronchovesicular. The constitutional disturbance 



DISEASES OF THE BRONCHI 207 

accompanying bronchopneumonia is more pronounced, and the 
dyspnea is of a more extreme grade. 

Pertussis, during the first week or ten days, cannot be differen- 
tiated from acute bronchitis; but after the development of the 
first *Svhoop" the diagnosis is readily made. A history of ex- 
posure to pertussis is often to be elicited. 

CHRONIC BRONCHITIS 

Clinical Pathology. — Chronic inflammation of the bronchial mu- 
cous membrane occurs secondarily to a great variety of bodily 
states. Adults and elderly persons are most frequently the sub- 
jects of chronic bronchitis, the disease constituting the regularly 
recurring ^'winter cough" of many persons past middle life. 

A certain percentage of cases of chronic bronchitis develop as 
the result of frequently repeated attacks of acute bronchitis. 
There is naturally great diversity of opinion as to the period at 
which an acute bronchitis shall be said to have become chronic, 
Gintrac including in the latter group any case which persists 
longer than forty days. 

In other instances the disease is secondary to circulatory dis- 
turbances in the lungs, developing as the result of valvular dis- 
ease of the left heart, aneurysm of the thoracic aorta, general 
arteriosclerosis, or renal disease. In this group should also be 
placed the cases developing so frequently in obese subjects. 

Next in frequency to these causes of chronic bronchial inflam- 
mation comes chronic pulmonary disease. Hypertrophic emphy- 
sema is quite constantly attended by chronic bronchitis, as are 
also chronic ulcerative phthisis, pneumonokoniosis, bronchiec- 
tasis, and bronchial asthma. 

Certain constitutional diseases are causative of or are fre- 
quently attended by chronic bronchitis. This is notably true of 
gout and uremia, particularly in elderly subjects of these mala- 
dies. Rachitic subjects are very prone to develop chronic bron- 
chial inflammation as are those of a strumous, scrofulous predis- 
position. Subjects of chronic eczema for some reason frequently 
suffer from chronic bronchial symptoms, this group of cases con- 
stituting the ^'endormoses" of Gueneau de Mussy. 

As the continual exposure to irritating gases and dusts is 
provocative of pneumonokoniosis and pulmonary fibrosis, so also 
are these factors in milder concentration causative of chronic 
bronchitis. These cases constitute the ''mechanical bronchitis" 



208 PHYSICAL DIAGNOSIS 

of Walslie. Similarly, constant inhalation of unwarmed air by 
month breathing dne to nasal obstruction results in chronic catar- 
rhal inflammation of the bronchial mucous membrane. 

Chronic bronchitis occurs in a hypertrophic and in an atrophic 
form. In the former there is proliferation of the mucous or 
goblet cells of the mucous membrane, which pour out a viscid 
grayish secretion containing innumerable desquamated epithe- 
lial cells mixed with bacteria. The lumen of the bronchus is 
diminished in numerous areas by hypertrophic thickening of the 
mucous membrane. In the atrophic form, on the contrary, the 
mucosa in certain areas of the bronchial distribution is thinned; 
the muscularis is replaced by fibrous connective tissue ; and the 
weakened bronchial wall shows fusiform or saccular ectases. 

In addition to the simple catarrhal form of the disease, chronic 
bronchitis occurs in the form of several modified or special forms ; 
notably as purulent hronchitis, the catarrhe sec of Laennec, hron- 
chorrhoea serosa or catarrhe pitiiiteux of Laennec, as fetid or 
putrid hronchitis, and as eosinophilic hronchitis. 

Piirident hronchitis, a form of extensive duration, is character- 
ized by the expectoration of large quantities of purulent sputum 
of offensive odor, the foulness of the sputum, however, not ap- 
proaching that of the putrid form of the disease. When the puru- 
lent expectoration is very abundant the term tronchohlenorrhea 
is applicable to the disease. These cases sometimes exhibit a 
febrile movement which may simulate chronic ulcerative phthisis; 
and in other instances the temperature is septic, with colliquative 
sweats^ causing excessive discomfort to the patient, and occasion- 
ally actually endangering life. 

The catarrhe sec of Laennec is a form of chronic bronchial in- 
flammation which is attended by paroxysms of dyspnea and 
cough, simulating the picture of bronchial asthma, but with the 
distinguishing feature of very scanty expectoration. Cough is 
more pronounced toward the end of the attack, and with the es- 
tablishment of free cough attended by expectoration the dyspnea 
is relieved to a moderate degree. The paroxysms of cough excite 
pain in the thorax which is usually circumscribed to definite lim- 
ited areas of the chest wall corresponding to the attachment of 
the diaphragm. 

The expectoration, which is absent during the initial dyspneic 
period of the disease, contains in addition to a few desquamated 
epithelial cells with leucocytes and bacteria, many small grayish 
pellets of mucus, the ''crachats perles" of Laennec. Cursch- 



DISEASES OF THE BRONCHI 200 

mann's spirals and Charcot-Levden crystals are occasionally pres- 
ent in the sputnm. 

Believed by Laennec to occur only in subjects of gouty diathe- 
sis, this form of chronic bronchitis undoubtedly has a predilection 
for those subjects; but it has been noted as an intercurrent con- 
dition in the course of other forms of chronic bronchitis and in 
cases of moderate pulmonary congestion, when this is not suffi- 
cient in degree to produce frank pulmonary edema. Catarrhe 
sec is very prone to cause emphysema, and the two conditions are 
not infrequently associated. 

The bronchial mucous membrane in subjects of this disease is 
hypertrophied and acutely congested, leading to diminution of 
the bronchial lumen and predisposing to emphysema. Aff'ecting 
in the main the smaller bronchi and the bronchioles, these are in 
certain instances completely occluded by the turgescence of the 
mucosa, constituting the ''catarrhal bronchostenosis" of Cantani. 

In hronchorrhea serosa, or catarrhe pituiteux of Laennec, the 
pathologic antithesis of catarrhe sec is observed. This form of 
chronic bronchitis is characterized by the expectoration of large 
amounts of fluid, which in cases of moderate duration is thin, 
clear and frothy, containing small numbers of Curschmann's spi- 
rals and Charcot-Leyden crystals; but which in cases of extensive 
duration is cloudy, mucopurulent, or finally purulent in char- 
acter. The expectoration is very abundant, as much as a liter 
being raised in twenty-four hours in many instances. Cough is 
persistent, and, occurring in paroxysms, has led to the name 
"asthma humidum" which is occasionally applied to the condition. 

The bronchial mucous membrane is atrophic, and the weight of 
the accumulating secretion predisposes to bronchiectasis, which is 
not infrequently present in the purulent form of the disease. The 
purely serous form, true bronchorrhea serosa, has been attributed 
to nervous hypersecretion. 

Fetid or putrid 'bronchitis is distinguished by the exceedingly 
foul odor of the expectoration, which contains characteristic small, 
gray pellets, composed of mucus, with bacteria, pus cells, fatty 
acid crystals and cellular detritus, Dittrich's plugs. The sputum 
is yellowish-gray, abundant, and upon standing separates into 
three layers: an upper of yellowish froth, a middle of transpar- 
ent clear fluid, and a lower of purulent sediment. In addition to 
putrid bronchitis, purulent expectoration occurs in bronchiec- 
tasis, chronic ulcerative phthisis with cavitation, pulmonary ab- 
scess and gangrene, and empyema with pulmonary fistula. Putrid 



210 PHYSICAL DIAGNOSIS 

■ * 

bronchitis is apt to produce aspiration pneumonia, pulmonary 
abscess, or gangrene of the lung, the patient exhibiting signs of 
sepsis, which are of grave prognostic import. 

In the eosinophilic hronchitis of Teichmiiller there are parox- 
ysms of dyspnea Avhich lead ultimately to emphysema of the 
apices and anterior borders of the lungs. The sputum is colorless 
and mucoid, containing many eosinophiles, desquamated epithelial 
cells and occasionally Curschmann's spirals and Charcot-Leyden 
crystals. Occurring in paroxysms, the disease is really to be con- 
sidered a rudimentary form of bronchial asthma in which the 
chronic catarrhal symptoms predominate the clinical picture. 

The ultimate result of persistent chronic bronchitis is pulmo- 
nary emphysema. The partial occlusion of the bronchioles com- 
bined with the paroxysms of violent cough are the prime factors 
in the production of this condition. However, the chronic bron- 
chial irritation also results in peribronchial fibrosis, which by 
favoring interstitial sclerosis of the lung, also predisposes to 
bronchiectasis from traction. In other instances signs of right 
heart incompetence are manifested, as the result of interference 
with the pulmonary circulation, and in the absence of emphysema 
there is evidence of chronic venous stasis. 

Physical Signs. — Inspection. — The subject of chronic bronchitis 
is liable to chronic shortness of breath, often attaining to the 
degree of actual dyspnea, upon moderate exertion. The parox- 
ysms of violent cough in certain cases are suggestive of bronchial 
asthma. In the cases in which emphysema is coexistent the bar- 
rel chest of this disease with its limitation of expansion is noted, 
while in the circulatory group of cases there is apt to be cyanosis 
and edema from venous stasis. 

Palpation. — Usually negative, palpation in cases associated with 
abundant secretion may reveal the presence of rhonchal fremitus 
of bilateral distribution. Vocal fremitus is little altered if in- 
deed at all. 

Percussion. — The percussion note in chronic bronchitis is often 
quite normal. However, in cases attended by emphysema the 
note is hyperresonant ; whereas in cases of fetid bronchitis asso- 
ciated with bronchiectasis, dullness is encountered over large 
superficially filled ectases, the note changing to hyperresonance 
or tympany upon the expulsion of the contents of the cavities. 
Similarly there is in cases of cardiac origin not infrequently im- 
pairment of resonance over the bases posteriorly as the result 
of moderate pulmonary edema. 



DISEASES OF THE BRONCHI 211 

Auscultation. — Auscultatory signs in clironic bronchitis are 
abundant and very variable. In clironic bronchitis of extensive 
duration the respiratory murmur is harsh and by reason of the 
accompanying emphysema expiration is prolonged. Rales of all 
types are audible over both sides of the thorax, particularly over 
the bases posteriorly, at the inferior angle of the scapula, and 
anteriorly in the infraclavicular and mammary regions. In simple 
chronic catarrhal bronchitis large and small rales are in evidence as 
is also the case in bronchorrhea serosa, associated with bronchi- 
ectasis. In catarrhe sec, on the contrary, the rales are dry, high 
pitched, and sibilant, moist rales being present in but small num- 
ber if indeed at all. 

Auscultation of the heart in chronic bronchitis yields variable 
and suggestive signs in many instances. In simple catarrhal 
bronchitis of comparatively brief duration the cardiac tones are 
unaltered; whereas in cases of cardiac origin and in cases which 
are associated with well-established emphysema, the second sound 
of the heart at the pulmonic area is accentuated; and in cases 
which are dependent upon chronic valvular disease the murmurs 
of the provocative lesions are audible. In cases of renal origin, 
on the contrary, the second sound at the aortic area is very fre- 
quently accentuated. 

Diagnosis, — With a history of chronic cough recurring every 
winter, with rales distributed universally throughout both lungs, 
unattended by fever or loss of weight, in an elderly person who 
presents a thorax approaching the emphysematous type, the diag- 
nosis of chronic catarrhal bronchitis is suggested. It should be 
borne in mind, however, that aortic aneurysm or mediastinal 
tumor are occasionally productive of chronic cough ; but in these 
cases there is apt to be more or less pronounced stridor owing 
to unilateral vocal cord paralysis. 

Catarrhe pituiteux, with its abundant, serous frothy expecto- 
ration, is apt to be confused with pulmonary edema ; Avhereas 
putrid bronchitis with its foul sputum is apt to simulate the clin- 
ical picture of bronchiectasis. In most cases a differential diag- 
nosis between putrid bronchitis and bronchiectasis with decompo- 
sition of the contents of the ectases may only be made when the 
latter disease forms cavities of sufficient size to give distinctive 
and definite ph^^sical signs. 

In dealing with a disease which is so frequently secondary to 
other pathologic changes in the thorax, the diagnosis cannot be 
considered complete until the causative lesion is in each case 



212 PHYSICAL DIAGNOSIS 

determined. In cases of cardiac origin auscultation of the pre- 
cordia frequently reveals the presence of regurgitant lesions or 
signs of myocardial degeneration; while in cases dependent upon 
chronic renal disease the aortic second sound is accentuated and 
frequently there are signs of left ventricular hypertrophy. Again 
in cases of putrid bronchitis associated with pulmonary abscess 
or gangrene, careful physical examination will elicit confirmatory 
signs of the conditions. The eosinophilic form of chronic bron- 
chitis is differentiated from bronchial asthma by the history in 
the latter disease of attacks of expiratory dyspnea and orthopnea 
dating from adolescence or early life, with intervals during which 
the patient is entirely free from pulmonary symptoms. The blood 
picture shows a higher degree of eosinophilia in true bronchial 
asthma. 

It is of the utmost importance in cases of long standing chronic 
bronchitis to exclude the presence of chronic ulcerative phthisis, 
as the former is often part and parcel of the latter. In such 
event a careful search should be made for disease of the heart, 
arteries, or kidneys which might be responsible for the chronic 
bronchial inflammation. It should be recalled that a nontubercu- 
lous chronic bronchitis is not attended by febrile elevation, 
marked anemia, or loss of weight. Moreover, the physical signs 
in chronic bronchitis are bilateral, whereas in phthisis they are 
apt to be unilateral and to manifest a predilection for the pul- 
monary apices. In purulent and putrid bronchitis the sputum 
contains characteristic bodies in the form of Dittrich's plugs, 
Curschmann's spirals, and Charcot-Leyden crystals, whereas 
tissue shreds and elastic fibers, signs of tuberculous excavation 
of the lung, and the tubercle bacillus are absent from the 
sputum. 

FIBRINOUS BRONCHITIS 

Clinical Pathology. — Fibrinous coagula are formed in the 
smaller bronchial tubes under a variety of conditions. They 
have been noted in chronic disease of the lungs and heart; as a 
result of the inhalation of irritative gases, notably ammonia 
gas; as the result of infection of the bronchial mucous mem- 
brane by the pneumococcus or the Klebs-Loeffler bacillus, in 
the last instance the morbid process constituting a bronchial 
diphtheria. Following hemoptysis fibrinous masses are not in- 
frequently expectorated, which may simulate those of fibrinous 
bronchitis. 



DISEASES OF THE BRONCHI 213 

Aside from these conditions, there are two conditions which 
may be classed as true fibrinous bronchitis with the expectora- 
tion of fibrinous moulds of the bronchial tubes amid paroxysms 
of dyspnea and cough. This essential fibrinous bronchitis oc- 
curs in two forms; namely, as acute filyrhwus troncJiitis, and as 
chronic idiopathic fihrinous hronchitis. The acute form of the 
disease is occasionally noted as a complication of the acute in- 
fectious fevers, notably in the course of scarlatina, measles, 
pneumonia, influenza, variola, tuberculosis, and typhoid fever. 
Fifteen cases of this type of the disease are reported by Bettman. 
Chronic idiopathic fibrinous bronchitis occurs as a chronic, re- 
current malady, and the disease invariably attacks the same por- 
tion of the bronchial tree. In Bettman 's collection of cases ten 
were accompanied by organic cardiac disease ; fourteen developed 
during the course of pulmonary tuberculosis; five cases were 
associated with bronchial asthma ; and four cases were attended 
by edema of the lungs. 

The distinguishing feature of the disease is the expulsion from 
the bronchi and bronchioles of branching, fibrinous casts with 
the expectoration at the conclusion of a paroxysm of dyspnea 
and cough, which is relieved by the expulsion of the casts. The 
casts, which correspond in shape and size to the ramifications of 
the portion of the bronchial system which lodged them, vary in 
length and have been found to exceed ten centimeters in length. 
The body of the cast, which is composed largely of superimposed 
laminae of fibrin with epithelial cells, leukocytes, bacteria, cellular 
detritus, and occasionally Charcot-Leydon crystals, corresponds 
in diameter with the lumen of the bronchial tube from which it 
was expelled. 

Much confusion still remains as to the exact nature of the 
pathologic changes which occur in the mucous membrane of the 
bronchi in the affected areas. Weigert and Kretschy reasoned 
that the epithelial surface must desquamate in order to render 
possible the formation of the casts. Bettman, quoting Schitten- 
helm, describes a desquamative catarrhal inflammation of the 
alveoli with exudation into the alveoli, bronchioles, and smaller 
bronchioles. 

Physical Signs. — Inspection. — During the paroxysms of dyspnea 
and cough which characterize the attacks the patient is usually 
orthopneic, the clinical picture simulating that of the paroxysm of 
bronchial asthma. The dyspnea is often relieved by the sudden 



214 PHYSICAL DIAGNOSIS 

• * 

copious expectoration, while in other instances the attack is at- 
tended by distressing cough with very scanty expectoration. 

Palpation. — As a rule, palpation yields but limited data in this 
disease. However, when one of the larger bronchi is occluded by 
a cast, vocal fremitus is absent over the distribution of its radicles, 
and the expansion of the corresponding side of the thorax is dimin- 
ished. 

Permission. — In the absence of concomitant disease of the lung, 
percussion of the thorax is usually negative in cases of fibrinous 
bronchitis. However, when a large bronchus is occluded the note 
is impaired over the area of the thorax corresponding to its dis- 
tribution, to become resonant once more upon the expulsion of the 
offending cast. Moreover, it is occasionally possible to elicit a 
moderately hyperresonant note over the adjacent pulmonary tis- 
sues in the presence of bronchial occlusion, as a result of compen- 
satory emphysema of the neighboring vesicles. 

Auscultation. — Moist rales are frequently encountered, while oc- 
casionally the bruit de drapeau is audible. When present, it is of 
considerable diagnostic value. The respiratory murmur is absent 
over the distribution of an occluded bronchus, only to become re- 
established with the expulsion of the cast and the restoration of the 
patency of the tube. The intensity of vocal resonance undergoes 
similar modifications under the same conditions. 

Diagnosis. — Fibrinous bronchitis with its attacks of paroxysmal 
dyspnea may readily be confounded with bronchial asthma. The 
ultimate differential diagnosis depends upon the recognition of 
typical fibrinous casts in the sputum. While the physical signs 
are rarely typical of the disease, the presence of the bruit de 
drapeau is of great aid in diagnosis; and Andral has called at- 
tention to the importance of the transient abolition of the res- 
piratory murmur over a circumscribed area of the thorax combined 
with normal pulmonary resonance. In all cases the presence of 
bronchial diphtheria and hemoptysis must be excluded. 

BRONCHIECTASIS 

Clinical Pathology. — Bronchiectasis is in the vast majority of 
cases a secondary disease, complicating previously existing dis- 
ease of the bronchi, the lungs, or the pleura. 

The dilatation may be produced by increased pressure exerted 
upon a weakened bronchial wall from within, or by traction 
exerted upon the bronchial wall from without. In chronic bron- 



DISEASES OF THE BRONCHI 215 

chitis of long standing, with its paroxysms of violent cough, 
combined with the accumulation of the abundant secretion in the 
purulent and putrid forms of the disease, the weakened bronchial 
wall is apt to yield and lead to bronchiectasis. The violent 
paroxysmal cough of pertussis may result similarly. Bronchial 
dilatation follows stenosis of the bronchi occurring as a result of 
syphilitic or tuberculous ulceration, and it has developed as a 
result of bronchial compression by mediastinal tumor or aneu- 
rysm. 

The traction of adhesions upon the bronchial wall in chronic 
interstitial pneumonia, pulmonary syphilis, and fibroid phthisis 
is one of the most productive etiologic factors in the production 
of bronchiectasis. In these cases the cicatricial bands may pass 
from a thickened pleura to the affected bronchus, or they may 
pass from one bronchus to another. Bronchiectasis has fol- 
lowed the lodgment of foreign bodies in the bronchi. In these 
cases Cohn holds that the dilatation develops at the site of the 
foreign body as a result of irritation and consequent ulceration, 
and not distal to it as a result of stenosis. Bronchiectasis occa- 
sionally develops in connection with lobar or lobular pneumonia, 
chronic ulcerative phthisis, and pulmonary neoplasm. More- 
over, bronchiectasis occurs in a congenital form, the "bronchiecta- 
sis universalis" of Grawitz. 

Bronchiectasis is not a common disease. The cases have usually 
developed in young adults and in persons of middle age ; and 
males have been affected with the disease more frequently than 
have females. 

The bronchial dilatations are found most frequently in the 
right lung, in which they affect principally the bronchi of the 
middle and lower lobes. The dimensions of the ectases are vari- 
able, ranging from a moderate increase in the lumen of the tube 
to large cavities in which the bronchial communication is often 
obliterated. Two principal forms of dilatation are encountered; 
namely, the saccular and the cylindrical. Cylindrical dilatation is 
most frequently observed in connection with the smaller bron- 
chial tubes; but it is also encountered in the larger bronchi; and 
the two forms, saccular and cylindrical, are not infrequently 
found in the same lung. 

The pulmonary tissue adjacent to the larger ectases presents 
areas of compensatory emphysema, alternating with areas of sclero- 
sis in which the pleura often participates. The number and dis- 
tribution of the bronchiectatic areas are always variable; but as 



216 



PHYSICAL DIAGNOSIS 



a rule a single large bronchiectasis occupies a position rather 
deep within the interior of the lung, whereas multiple small bron- 
chiectases show a more superficial distribution. 

The state of the mucous membrane of the dilatations varies. In 
certain instances scarcely altered, in practically all extensive 
dilatations it is thickened, with polypoid elevations upon the 
surface ; while in cavities containing abundant secretion the 
mucosa is not infrequently ulcerated. The exudation from the 
walls of extensive bronchiectatic dilatations is usually purulent 




Fig. 102. — Sacculated bronchiectasis. (Pottenger, after Powell and Hartley.) 



and abundant; but occasionally it is scanty and cheesy in con- 
sistence. 

The expectoration, which represents the contents of the ectases, 
is gray or brown in color, mucopurulent in character, and in cases 
with large cavities is abundant and fetid. Upon standing, the 
sputum separates into three strata ; an upper of brownish froth, 
a middle of semiopaque fluid, and a lower composed of granular 
sediment containing cellular detritus, bacteria, fatty acid crystals, 
leucocytes, and occasionally Charcot-Leyden crystals. The dis- 
ease is occasionally, though rarely, attended by hemoptysis. 



DISEASES OF THE BRONCHI 217 

Bronchiectasis not infrequently results in emplivsema, and these 
cases, constituting the "dry cases" of the disease, give the most 
favorable prognosis. In cases with large ectases and cavitation, 
associated with the collection of abundant secretion, abscess or 
gangrene of the lung is apt to supervene. Abscess of the brain 
has been noted in connection with bronchiectasis, usually upon 
the side corresponding to the site of the dilatation. 

Physical Signs. — Inspection. — The presence of small bronchiecta- 
ses produces no characteristic physical signs. In the fully estab- 
lished case of bronchiectasis, hoAvever, in which the dilatations 
have attained considerable size, there is impairment of expansion 
of the corresponding side of the thorax and occasionally retraction 
of the affected side with drooping of the shoulder. The decubitus 
of the patient, while variable, in advanced cases is suggestive ; as 
the patient usually prefers to lie upon the affected side, and a 
change of posture is frequently followed by a severe paroxysm of 
cough due to shifting of the contents of the cavities. 

Fluoroscopy in advanced cases is apt to reveal a shadow in the 
area of an extensive dilatation which contains mucopurulent 
material, this area clearing perceptibly upon evacuation of the 
contents during a paroxysm of cough. Clubbing of the finger- 
tips from enlargement of the terminal phalanges is present in 
many cases of long standing. 

Palpation. — In the presence of a large bronchiectatic cavity with 
patent bronchial communication, situated superficially in the 
thorax, vocal fremitus is very markedly increased when the cavity 
is empty, to become abolished over the same area when the cavit}^ is 
filled with fluid. 

Percussion. — The findings upon percussion in bronchiectasis are 
variable, depending upon whether the cavity under investigation 
is empty or is filled with secretion. If the cavity contains fluid, 
even though it has a patent bronchial outlet, the percussion note 
is flat ; whereas, if the cavity is empty, it yields tympany or a 
cracked-pot sound upon percussion. In suitably situated cavities 
all of the signs of pulmonary cavitj^, such as Wintrich's change of 
sound, Friedreich's respiratory change of sound, and the change 
of sound of Gerhardt, may be elicited. 

In ever}- case in which the signs of cavitation are evanescent, 
present and absent at successive examinations, the possibility of 
bronchiectasis should be borne in mind, as these cavities fill with 
secretion which masks all physical signs, and then the signs of 



218 PHYSICAL DIAGNOSIS 

■ » 

cavitation reappear with the evacuation of the contents of the 
dilatations. 

Auscultation. — In cases of bronchiectasis which are of relatively 
short duration, auscultation yields only the signs of chronic 
bronchitis, puerile breath sounds, and rales. If, however, a rather 
large dilatation be properly situated with reference to its bron- 
chial communication, amphoric breathing is encountered. If a 
large dilatation is situated near the periphery of the lung, and 
if it has a free bronchial outlet, vocal resonance is very greatly 
exaggerated, perhaps to the extent of affording bronchophony or 
whispering pectoriloquy. 

Diag'nosis. — Cases of moderate bronchiectasis are distinguished 
from chronic bronchitis with difficulty, of which disease indeed 
it is often a sequela. In well-established cases, however, in which 
more extensive organic change has occurred in the bronchial 
system, the expectoration of a copious amount of mucopurulent 
sputum at one time, followed by an absence of expectoration for 
several hours, is suggestive of bronchiectasis; and when in addi- 
tion signs of cavitation can be elicited over the base of the lung 
the presence of bronchiectasis may be assumed. 

Differential Diagnosis. — The most important point in differ- 
ential diagnosis is the possibility of mistaking bronchiectasis for 
chronic ulcerative phthisis with cavity formation. However, 
vomicae in the latter disease are usually situated in the pulmo- 
nary apex, a region of the lung which is rarely invaded by 
bronchiectasis. Moreover, percussion of the lung adjacent to the 
cavity in bronchiectasis is apt to yield hyperresonance due to 
compensatory emphysema, whereas in phthisis similar percussion 
elicits dullness of consolidation, which at this advanced stage of 
the disease is usually demonstrable also upon percussion of the 
opposite lung. In phthisis the sputum is raised at frequent inter- 
vals and is apt to contain the tubercle bacillus and elastic fibers. 
Moreover, chronic ulcerative phthisis produces characteristic de- 
formity of the thorax with fever, anemia, and night sweats, while 
the course of the disease is progressively downward to a fatal 
termination. In bronchiectasis, on the contrary, unless it de- 
velops upon a tuberculous basis, the physical signs persist for a 
long period, while the patient remains in a comparatively good 
state of health. 

Empyema with rupture into a bronchus is attended by the sudden 
expectoration of a large amount of i^urulent sputum ; but instead 
of signs of cavity over the lower lung, there is the dullness of the 



DISEASES OF THE BRONCHI 219 

original empyema, with the probable presence of Grocco's sign. 
Pulmonary abscess and gangrene, which may simulate bron- 
chiectasis, are excluded by their more rapid evolution, and by 
the presence of signs of sepsis. Putrid bronchitis is excluded by 
its bilateral distribution, 

BRONCHIAL ASTHMA 

Clinical Pathology. — Bronchial or spasmodic asthma consists 
essentially of a paroxysmal dyspnea which is almost entirely ex- 
piratory in type, the subject of the disease during the paroxysms 
being unable adequately to expel the air from the lungs. Bronchial 
asthma has nothing in common with the so-called cardiac asthma or 
renal asthma. 

Numerous theories and hypotheses have been advanced in the 
attempt to explain the cause of bronchial asthma. It is generally 
agreed that there is a marked neurotic element in the subject of 
the disease. It is suggested that the attack is initiated by a 
sudden spasm of the bronchial musculature ; also that the ob- 
stacle to the egress of the air from the lungs is due to narrowing 
of the lumen of the bronchioles by temporary and transcient 
turgescence of the mucous membrane. Curschmann holds that 
the underlying cause is a special form of inflammation of the 
smaller bronchial tubes, the so-called bronchiolitis exudativa of 
this author. Spasm of the diaphragm has been advanced as a 
probable cause of the paroxysm. 

Very little has been recorded with reference to the morbid 
anatomy of the disease, as but half a dozen autopsies are con- 
tained in the literature. In such cases as have been examined, 
the ciliated epithelium of the bronchi has been found in a state 
of desquamation, with bronchial congestion and exudation rich 
in eosinophilic cells. The blood during the paroxysm of bronchial 
asthma contains an excess of eosinophiles, these cells represent- 
ing 25 per cent to 35 per cent of all the leucocytes. 

The sputum in bronchial asthma is characteristic of the disease. 
In the early stages it is scanty and very tenacious, containing 
Curschmann 's spirals and Charcot-Leyden crystals. Macroscopi- 
cally Curschmann 's spirals are white or yellow, taking the form 
of twisted threads or of small balls. The length of the spiral 
rarely exceeds half an inch, but it may exceed two inches in 
certain instances. Under the microscope they appear as mucous 
threads containing a clear central fiber, around which are w^ound 



220 



PHYSICAL DIAGNOSIS 




Fig. 103. — Curschmann's spirals. (From Brown.) 




Fig. 104. — Eosinophiles. A considerable percentage of the pus cells of asthmatic 
sputvnn are eosinophiles. This is probably indicative of chronic intoxication. (From 
Brown.) 



DISEASES OF THE BRONCHI 221 

many fine fibrils. Eosinophiles are frequently found entangled 
in the meshes of the fibrils. Charcot-Leyden crystals occur as 
colorless, pointed, octohedral crystals, the average length of 
which is about three times the diameter of a red blood cell. They 
are often absent in freshly expectorated sputum, but they appear 
after it has stood for a short time. 

During the later stages of the attack these two pathognomonic 
elements of the sputum disappear, the expectoration becoming 
more abundant and mucopurulent in character. 

Chronic bronchitis is frequently a concomitant affection in 
subjects of bronchial asthma; while the repeated paroxysms of 
the disease, with their typical expiratory dyspnea, tend to the 
production of emphysema and bronchiectasis. 

Physical Signs. — Inspection. — During the paroxysm of bronchial 
asthma, which is very abrupt in onset, dyspnea of the expiratory 
type dominates the other physical signs. There is little if any 
increase in the number of respirations ; and indeed, owing to the 
great prolongation of expiration, the number may be actually 
diminished. Inspiration is short and powerful, but adds little to 
the degree of expansion of the thorax, which remains fixed in a 
position of relatively full inspiration. Bamberger describes the 
inspiratory phase as that of normal inspiration with the participa- 
tion of the accessory muscles of respiration in the act. Expiration, 
which lasts three to four times as long as inspiration, follows the 
latter promptly without the intervention of the normal pause be- 
tween these phases, the accessory muscles of expiration being called 
into play in the attempt to empty the thorax. 

During the course of the paroxysm the patient becomes orthop- 
neic ; the cervical veins become engorged ; and the lips, face, and 
hands are apt to become cyanotic. The thorax is large and semi- 
fixed in the position of inspiration; the diaphragm is depressed; 
and the moderate degree of expansion during inspiration is exerted 
largely in the vertical direction, the thorax rising and falling en 
masse much in the same manner as in hypertrophic emphysema. 

Palpation. — During the paroxysm vocal fremitus, if its intensity 
can be determined, is diminished as a result of the rarefaction of 
the transient acute vesicular emphysema or of bronchial obstruc- 
tion by turgescence of the bronchial mucosa or of spasm of the 
bronchial muscles. Rhonchal fremitus is present to a striking 
degree, and is bilateral in its distribution. The cardiac impulse is 
often masked by the concomitant emphysema of the anterior jduI- 



222 PHYSICAL DIAGNOSIS 

■ » 

monary borders. Pulsation is frequent in the cervical vessels and 
in the episternal notch. 

Percussion. — The quality of the percussion note in bronchial 
asthma varies from a moderate hyperresonance during mild attacks 
to a note which closely approximates tympany in severe attacks in 
emphysematous subjects. The limits of pulmonary resonance are 
extended in all directions, upward in the supraclavicular regions, 
downward encroaching upon the hepatic and splenic dullness, and 
anteriorly, causing diminution in the area of cardiac dullness. In 




Fig. 105. — Charcot-Leyden crystals. These crystals are formed in sputum of chronic 
bronchitis, especially if asthma exists. They have been repeatedly found in other loca- 
tions. They seem to indicate decomposition. (From Brown.) 

advanced cases, w^hich are associated with marked emphysema, the 
area of cardiac dullness is frequently displaced downward. The 
respiratory excursion of the pulmonary borders is strikingly dimin- 
ished in these subjects. 

Auscultation. — The vesicular murmur is obscured by numerous 
loud, sibilant and sonorous rales, which are so pronounced as fre- 
quently to be audible at some distance from the patient. Late in 
the paroxysm, after the bronchial secretion has become freely es- 



DISEASES OP THE BRONCHI 223 

tablished, the dry rales give place to numerous moist and bubbling 
rales. Inspiration is frequently entirely inaudible, whereas the 
expiratory phase of the vesicular murmur is greatly prolonged and 
is punctuated with numerous rales. 

Diagnosis. — Owdng to the paroxysmal character of the asth- 
matic attack, with its well-marked expiratory dyspnea dotted 
with rales, the overdistention and relative fixation of the thorax, 
and the characteristic elements of the sputum, a diagnosis of 
bronchial asthma is often readily made. However, it is not infre- 
quently necessary to differentiate the disease from attacks of 
dyspnea arising from other causes. Prominent among the latter 
is dyspnea due to laryngeal obstruction from spasm or edema of 
the glottis. In this case the dyspnea is distinctly of the inspira- 
tory type, often with stridor, and as a rule is attended by marked 
respiratory movement of the larynx. There is often aphonia; the 
thorax is of normal size ; and there is apt to be inspiratory reces- 
sion of the lower intercostal spaces. The absence of rales in the 
presence of laryngeal obstruction is in marked contrast to the 
numerous rales of the asthmatic attack. 

Differential Diagnosis.^ — Bronchial compression by enlarged 
glands, tumors, or aneurysm, and stenosis resulting from the in- 
gestion of foreign bodies are to be excluded before a diagnosis 
of bronchial asthma is to be made upon the presence of paroxysms 
of severe dyspnea. 

Hypertrophic emphysema, chronic bronchitis, and bronchial 
asthma are often differentiated with difficulty, and indeed they 
are frequently concomitant diseases. HoAvever, in pure hyper- 
trophic emphysema the expiratory prolongation and the attend- 
ant physical signs are constant and are not i3aroxysmal in their 
manifestation. Moreover, in emphysema the vital capacity of 
the lungs is permanently diminished, whereas in bronchial 
asthma in the intervals between the paroxysms this capacity 
closely approximates the normal, to become abruptly impaired 
during the asthmatic attack. Moreover, the microscopic examina- 
tion of the sputum in bronchial asthma reveals the presence of 
characteristic elements. As to chronic bronchitis and bronchial 
asthma, the former may be assumed to be present when in the 
intervals between the paroxysms physical signs of moist bronchial 
inflammation are persistently discovered upon successive exami- 
nations. 



224 PHYSICAL DIAGNOSIS 

TRACHEOBRONCHIAL STENOSIS 

Clinical Pathology. — Diminntion of the lumen of the tracheo- 
bronchial system arises from intrabronchial and from extra- 
bronchial causes. Intrabronchial stenosis occurs Avith tracheal 
and bronchial diphtheria, as the result of the development and 
growth of polypoid tumors of the mucous membrane, as a conse- 
quence of turgescence of the mucosa following the inhalation of 
irritating gases, in cicatricial formations following syphilitic 
ulceration, and in the i3resence of foreign bodies. The trachea 
may be compressed above the bifurcation by an enlarged thyroid 
gland or a mediastinal tumor, as also in the course of caries of the 
vertebral column and by extension of esophageal disease. Below 
the bifurcation the tracheobronchial tree is liable to compression 
from aortic aneurysm, pericardial effusion, or an excessively 
hypertrophied heart, pulmonary tumor, or enlarged bronchial 
glands. Aneurysm of the ascending aorta usually compresses the 
right bronchus, whereas aneurysm of the arch or of the descend- 
ing aorta causes compression of the left bronchus. 

The ultimate effect of the stenosis upon the lungs varies with 
the degree and with the site of the obstruction. Stenosis above 
the tracheal bifurcation results in deficient, but prolonged ex- 
pansion of the lungs. Total and permanent obstruction of a 
principal bronchus results in ultimate collapse of the lung which 
it supplies. Complete stenosis of a bronchial tube of the second or 
third order results in atelectasis of a considerable area of a lung; 
while stenosis of several of the small bronchi exerts little influence 
upon the lung as a whole, as the area of atelectasis is compen- 
sated by vicarious expansion of the adjacent pulmonary lobules. 

Upon complete stenosis of any portion of the tracheobronchial 
system, the air in the infundibula supplied by the affected tube 
is gradually absorbed and the pulmonary lobules collapse, con- 
stituting the so-called ohturation atelectasis. The lobules imme- 
diately adjacent to an area of atelectasis are compensatorily 
emphysematous, and by their vicarious expansion and increased 
aerial content mask the physical signs which would naturally be 
produced by the area of atelectasis. 

Physical Signs. — The physical signs of tracheobronchial steno- 
sis vary with the site and the degree of the obstruction. In 
tracheal obstruction the signs are bilateral in their distribution, 
affecting both lungs to an equal degree ; whereas in stenosis of a 
principal bronchus the physical manifestations of the condition 
are unilateral, but affect an entire lung. In stenosis of a small 



DISEASES OF THE BRONCHI 225 

bronchus physical signs are slight in degree or are entirely ab- 
sent. 

Inspection. — In tracheal stenosis the clinical picture is that of 
inspiratory dyspnea with inspiratory retraction of the lower inter- 
costal spaces and epigastrium, and with bilateral diminution in the 
thoracic expansion. In extreme grades of tracheal stenosis there is 
cyanosis of the mucous membranes and extremities. In stenosis of 
a principal bronchus, expansion is limited over the side of the 
affected lung. Tracheobronchoscopy is often of service in the de- 
tection of stenosis, revealing the site and the degree of the ob- 
struction. 

Palpation. — Vocal fremitus is diminished or absent over the 
distribution of the obstructed tube, the alteration in intensity being 
bilateral in tracheal stenosis, and unilateral in bronchial obstruc- 
tion. 

Percussion. — In stenosis of a principal bronchus the percussion 
note is dull over the area of distribution of the bronchus, or over 
the entire lung. In minor degrees of stenosis the note is scarcely 
changed, and indeed it may be hyperresonant as a result of the 
compensatory emphysema of the infundibula adjacent to the area 
of atelectasis. 

Auscultation. — Upon auscultation over the area of an occluded 
bronchus of considerable magnitude the respiratory murmur is 
feeble or is entirely abolished, while over the opposite lung it is 
exaggerated or puerile. Coarse, sonorous rales are occasionally to 
be elicited over the sit? of the obstruction. Vocal resonance is 
abolished over the affected lung in the presence of obstruction of 
a principal bronchus; but it is little affected in minor degrees of 
stenosis. 

Diagnosis. — The presence of inspiratory dyspnea, sibilant and 
sonorous rales, confined to a circumscribed area, unilateral de- 
ficiency of expansion and dullness over an entire lung, are signs 
suggestive of obstruction of a principal bronchus. In cases of steno- 
sis above the tracheal bifurcation it is important to differentiate 
laryngeal from tracheal stenosis. In laryngeal stenosis there is 
vigorous respirator}" movement of the larynx ; the head is fixed and 
thrown somewhat backward ; and the respiration is stridulous. The 
employment of the laryngoscope reveals the constriction or the ob- 
structing body. Tracheal stenosis is attended by less stridor, with 
limitation of the lar3'ngeal movement during respiration, and fre- 
quently the patient is orthopneic. Fluoroscopy reveals the site 
of foreign bodies when these are the underlying cause of the 
stenosis. 



CHAPTER IX 
CIRCULATORY DISTURBANCES OF THE LUNGS 

PULMONARY CONGESTION (Congestion of the Lungs) 

Clinical Pathology. — Congestion of the lungs occurs in two 
forms; namely, as active congestion, and as passive congestion. 

Active congestion of the lungs occurs in the early stages of in- 
flammation of these organs, as in the period of engorgement of 
lobar pneumonia. But active congestion of the lungs frequently 
occurs in conditions which do not attain the gravity of the first 
stage of lobar pneumonia ; notably after the inhalation of irritating 
gases, of hot or cold air ; and it occurs as a collateral congestion due 
to disease of an adjacent area of the lung. Active pulmonary con- 
gestion while not usually dangerous in itself, has in rare instances 
terminated fatally. Postmortem the lung in active congestion is 
enlarged, is deep red, its consistence is increased, yet the lung is 
crepitant and will float when placed in water. 

Passive congestion of the lungs occurs in two forms ; namely, as 
mechanical congestion, and as hypostatic congestion of the lungs. 

Mechanical congestion of the lungs results from an obstacle which 
is interposed to the free return of blood from the lungs to the 
heart. The most common cause operating in this manner is mitral 
regurgitation, while a less frequent cause is a tumor pressing upon 
the pulmonary veins. Mitral stenosis and aortic insufficiency and 
stenosis operate similarly to produce mechanical congestion of the 
lungs. 

Hypostatic congestion of the lungs is encountered in adynamic 
and asthenic states, particularly in elderly subjects who have been 
long in the recumbent posture during a continued fever or chronic 
wasting disease. The congestion in this instance is localized to the 
posterior and inferior portions of the lungs, and is largely de- 
pendent upon general asthenia and relaxation of the pulmonary 
vessels. That it is not entirely due to the supine posture is evinced 
by the fact that it only occurs in subjects who are weakened by 
disease. 

In passive congestion of the lungs the vessels of the lung are 
dilated and the interalveolar septa are distended with fluid, while 

226 



CIRCULATORY DISTURBANCES OF THE LUNGS 227 

the alveolar spaces contain serous fluid, desquamated alveolar 
cells containing- blood pigment, and a few leucocytes and red blood 
cells. 

Physical Signs.^ — Inspection. — In pulmonary congestion the res- 
piratory movements of the thorax are hurried but are limited in 
amplitude, the degree of thoracic expansion being below the normal 
degree. In acute congestion the face exhibits a variable degree of 
cyanosis; the expression is that of great anxiety; and the alse nasi 
move with respiration. 

Palpation. — In active congestion palpation reveals a moderate 
exagg:eration of vocal fremitus, which is most readily detected over 
the bases posteriorly. In passive congestion, on the contrary, there 
is diminution of the fremitus over this area of the thorax. 

Percussion. — In active congestion of the lungs the percussion 
note is apt to be slightly hyperresonant, as a result of the increased 
tension of the pulmonary tissues ; whereas in passive congestion 
there is impairment of resonance over the bases posteriorly, owing 
to the gravitation of the blood to these regions of the pulmonary 
system. 

Auscultation reveals in active congestion bronchovesicular breath- 
ing ; and, in cases of passive congestion shows in addition the valvu- 
lar lesion which is responsible for the congestion. In each instance 
the pulmonic second sound is accentuated as a result of the in- 
creased tension in the pulmonary circulation. In passive 
congestion moist or bubbling rales are not infrequently audible 
over the bases posteriorly. 

Diagnosis. — Dyspnea with anxious facies, in conjunction with 
a history of violent physical exertion, or exposure to irritant 
vapors or in the presence of active pulmonary disease, with 
limited excursion of the thorax is suggestive of acute pulmonary 
congestion, particularly if the acute symptoms develop abruptly 
without warning. The presence of dullness, impaired vocal frem- 
itus, and moist or bubbling rales over the bases posteriorly in an 
asthenic or bed-ridden patient, is suggestive of passive congestion 
of the lungs ; while, if a valvular lesion of the heart is coupled 
with the respiratory findings, the diagnosis is yet more probable. 

PULMONARY EDEMA (Edema of the Lungs) 

Clinical Pathology. — Edema of the lungs occurs in an acute and 
a chronic form and as general and local edema. 

Acute pulmonary edema complicates the acute infectious diseases, 



228 PHYSICAL DIAGNOSIS 

as during the course of lobar or lobular pneumonia, scarlatina, in- 
fluenza, acute rheumatic fever, variola, and typhoid fever. Less 
frequently it has developed during pregnancy and in hysterical 
patients. 

Chronic pulmonary edema occurs as a result of cardiac weakness 
during the course of myocarditis, valvular disease, chronic inter- 
stitial nephritis, or general arteriosclerosis. 

General pulmonary edema involves the whole of both lungs, the 
manifestations of the stasis being more marked in the bases as a 
result of gravitation of the fluid toward the dependent portions 
of the lungs. The lung of general pulmonary edema is sodden, and 
heavy ; the alveoli of the bases contain serous fluid, while the inter- 
alveolar walls are thickened and edematous. The lung pits upon 
pressure, and upon section serous fluid exudes from the surface of 
the section. The alveoli contain numerous desquamated alveolar 
epithelial cells which contain blood pigment, the so-called "heart- 
failure cells." 

Local pidmonary edema occurs as a collateral edema about foci 
of active pulmonary inflammation in the course of pneumonia, 
phthisis, and pulmonary infarction. In these cases the signs of 
the primary affection in the main obscure those of the local edema. 

General pulmonary edema is attended by the expectoration of 
abundant, clear, thin, frothy sputum, which is raised in large 
quantities. 

Physical Sig^ns. — Inspection. — The subject of pulmonary edema 
is suddenly siezed with dyspnea, which rapidly progresses to 
orthopnea, with anxious facies, and frequently with cyanosis of the 
lips and buccal mucosa. Thoracic expansion is diminished in extent, 
but is increased in frequency. There is constant, harassing cough, 
the cough of the wet lung, which is attended by the raising of 
abundant, frothy expectoration. 

Palpation.— Vocal fremitus is diminished in intensity over the 
bases of the lungs, while rhonchal fremitus, the tactile equivalent 
of the numerous moist rales which are present, is well brought to 
the fore. The skin of the extremities is moist and cold. The pulse 
is rapid, with diminution in the volume and force of the waves. 

Percussion. — The resonance of the percussion note is impaired 
over the bases posteriorly, whereas over the anterior surface of the 
chest in the infraclavicular and mammary regions skodaic reso- 
nance is not infrequently encountered. 

Auscidtation. — The respiratory murmur over the infraclavicular 
and mammary regions is commonly bronchovesicular, while over 



CIRCULATORY DISTURBANCES OF THE LUNGS 229 

the bases vesicular respiration is masked by numerous moist and 
bubbling rales. The heart sounds are increased in frequency, and 
exhibit a diminution in their intensity, save that the pulmonic sec- 
ond sound is frequently moderately accentuated. In extreme cases 
of general pulmonary edema, associated with cardiac dilatation, 
embryocardia is frequently present late in the course of the disease. 

Diagnosis. — The diagnosis of pulmonary edema rests upon the 
occurrence of dyspnea, frequently amounting to orthopnea, accom- 
panied by impairment of resonance and moist rales over the pul- 
monary bases, in a subject with an obstacle to the return of blood 
to the left heart or in an asthenic state from an acute infection or 
the subject of chronic nephritis or arteriosclerosis. 

Pulmonary edema is differentiated from bronchial asthma by the 
fact that in the former the dyspnea involves both phases of the res- 
piratory cycle, and by the essential characteristics of the expectora- 
tion in the two affections. 



PULMONARY INFARCTION 

Clinical Pathology. — Infarction of the lung occurs as a result 
of occlusion of one or more terminal branches of the pulmonary 
arteries. The condition develops most frequently in connection 
wuth valvular heart disease, particularly with acute or chronic 
endocarditis. Pulmonary infarction is almost invariably of the 
hemorrhagic type. 

The areas of infarction are situated most frequently in the 
lower lobes, and involve the right lung more frequently than the 
left. Usually of limited extent, a pulmonary infarct may become 
very extensive, involving the greater part of a lobe of the lung. The 
infarcts are commonly situated at the periphery of the lung ; they 
are wedge-shaped ; and the base of the wedge is directed toward 
the free surface of the lung. When recent, the areas of infarc- 
tion are dark red upon section, resembling a blood clot. Later, 
as organization progresses and the hemoglobin is partially re- 
moved by phagocytes, they assume a denser consistence and a 
yellowish color. Eventualh% in the absence of pyogenic organ- 
isms, the infarct undergoes organization, leaving a puckered scar 
at the site of infarction. The pleura overlying an area of in- 
farction exhibits signs of local inflammation. 

Microscopically the alveoli of the lung in the area of infarction 
are filled with erythrocytes in various stages of disintegration. 



230 PHYSICAL DIAGNOSIS 

■ • 

The vessels of the alveolar walls are likewise filled with red blood 
cells and in places are apt to exhibit thrombus formation. 

The ultimate termination of a pulmonary infarct depends upon 
the character of the causative embolus. If the embolus which oc- 
cluded the terminal artery is noninfectious, the infarct gradually 
undergoes organization, and eventually is converted into a mass 
of cicatricial tissue at the site of infarction. If, on the contrary, 
the embolus is of septic origin, the area of infarction is frequently 
the point of incidence of a pulmonary abscess or of pulmonary 
gangrene. It is probable that in the case of large areas of in- 
farction, involving the major portion of a lobe of the lung, 
partial resolution analogous to that which follows the consolida- 
tion of lobar pneumonia ensues. 

Infarction of the lung is not infrequently attended by the 
expectoration of viscid, mucoid sputum containing numerous 
erythrocytes, and occasionally by frank hemoptysis. 

Physical Sig'ns. — The signs which are referable to pulmonary 
infarction are variable, depending as they do upon the number, 
the size, and the distribution of the infarcts. In the case of small 
infarcts and of infarction of central portions of the lung, physical 
signs may be entirely lacking ; or the only signs elicited may be 
referable to the associated pleural inflammation, and may be in 
no way distinctive of infarction. 

Inspection. — In cases of extensive pulmonary infarction the res- 
piratory excursion of the thorax is limited upon the side of the 
disease. In addition, the subject is apt to exhibit moderate or 
severe dyspnea, with anxious facies and occasionally hemoptysis. 

Palpation. — Palpation may show increased vocal fremitus if the 
area of infarction is of considerable extent and is situated near the 
periphery of the lung ; whereas, if the infarct is centrally placed, 
near the root of the lung, no alteration of vocal fremitus is demon- 
strable. "When a peripheral infarct overlies a principal bronchus, 
vocal fremitus is markedly exaggerated. 

Percussion. — Over large infarcts dullness is elicited upon per- 
cussion; whereas in the case of a large infarct which is superim- 
posed upon a principal bronchus, the tympany of the bronchus is 
engrafted upon the dullness of the percussion note. Gerhardt calls 
attention to the frequency of pulmonary infarction upon the right 
side in the area of the lung lying between the vertebral column, 
the diaphragm, and the angle of the scapula, whence the importance 
in this disease of signs of consolidation over this area. 

Auscultation. — In suitably situated infarcts with reference to a 



CIRCULATORY DISTURBANCES OF THE LUNGS 231 

main bronchus, lond, bronchial or tubular breath sounds are elicited 
upon auscultation, as well as rales which are transmitted from the 
bronchial tube. In cases of multiple infarcts, or of deeply seated 
infarction, the breath sounds are at the most bronchovesicular, and 
in many instances they are frankly vesicular. 

Pleural friction is frequentlj^ to be elicited over areas of super- 
ficial infarction; and indeed in the case of infarction of limited 
extent, involving* the peripheral portion of the lung, this is occa- 
sionally the only sign of the disease. 

Diagnosis. — The physical signs of infarction of the lung are 
essentially those of pulmonary consolidation, and the diagnosis of 
infarction is made with difficulty. ^Yhen signs of consolidation 
are elicited in a patient suffering Avith valvular heart disease, 
from which pulmonary embolism might arise, infarction of the 
lung becomes a possibility; and, when the physical signs of con- 
solidation are attended by hemoptysis, jDulmonary infarction may 
be assumed to be present. As the area of infarction is frequently 
situated in the lower lobe of the right lung posteriorly, the 
physical signs of consolidation simulate closely those of lobar 
pneumonia. 

An infarct of moderate size occupying a central portion of the 
lung produces no physical signs by which a diagnosis of infarc- 
tion may be made. A limited, superficial infarct, on the con- 
trary, is apt to produce a local friction rub, which is apt to be 
mistaken for a simple pleurisy. Septic infarction, if extensive, 
is attended by signs of septic intoxication, with the supervention 
of signs of pulmonary abscess or of pulmonary gangrene. 



CHAPTER X 
DISEASES OF THE LUNGS 

LOBAR PNEUMONIA (CROUPOUS, OR FIBRINOUS 
PNEUMONIA) 

Clinical Pathology. — Lobar, croupous, or fibrinous pneumonia 
is an inflammation of the lung, which is attended by a variable 
degree of constitutional reaction and toxemia. 

The causative microorganism of lobar pneumonia is the pneu- 
mococcus or Diplococcus pneumoniae, first discovered in the 
sputum of pneumonia patients by Sternberg and Pasteur in 1880, 
and recognized as the cause of the disease by Fraenkel in 1884. 
The organism may be found in pure culture in the sputum of 
pneumonia patients or associated with the streptococcus, staphyl- 
ococcus, or Friedlander's bacillus. Lobar pneumonia is very 
prevalent at the extremes of life, affecting especially young in- 
fants and elderly persons ; but no age is exempt from the disease. 
The majority of cases develop during the late winter and the 
early spring months. 

The morbid pulmonary changes incident to lobar pneumonia 
present four fairly well-defined stages; namely, the stage of en- 
gorgement, the stage of red hepatization; the stage of gray 
hepatization; and, if the patient recovers from the disease, the 
stage of resolution. However, these stages of the inflammation 
are not invariably recognizable as distinct and separate entities; 
and it is not uncommon to find one stage more or less blended 
with another. 

The stage of engorgement is of brief duration, rarely exceeding 
twenty-four hours, as it is early followed by hepatization of the 
lung. During the period of active hyperemia which constitutes 
the stage of engorgement, the lung is dark red in color, and firm 
to the touch; but it is still crepitant, and the lung will float if 
placed in water. Microscopically during this stage the capillaries 
are distended with erythrocytes ; the alveolar walls are thick- 
ened; and the alveolar spaces contain a variable number of 
erythrocytes, leucocytes, and desquamated epithelial cells. 

During the stage of red hepatization the pulmonary tissue in 

233 



DISEASES OF THE LUNGS 233 

the portion of tlie lung which is the site of the disease is solid, 
firm, and devoid of air. The lung is slightly enlarged, and fre- 
quently the surface presents indentations corresponding to the 
ribs with which it is in contact. Upon section, the surface of 
section is dry, reddish or brown in color, and very friable. Upon 
scraping the cut surface with the knife, small fibrinous plugs are 
apt to come away from the cut surface of the lung. The lung 
is not crepitant in the area of the disease; and a section of the 
lung will sink when placed in water. Microscopically the alveoli 
are filled with a dense, fibrinous exudate, which contain erythro- 
cytes, leucocytes, bacteria, and desquamated epithelial cells, em- 
bedded and entangled in a matrix of fibrin, the erythrocytes 
predominating during this stage of the disease. 

In the stage of gray hepatization the pulmonary tissue loses 
its reddish color upon section, the surface of section presenting 
a gray or grayish-white appearance. Section shows a moister 
surface than in the preceding stage, and but few fibrinous plugs 
come away upon scraping the surface with the knife. Micro- 
scopicalh^ polymorphonuclear leucocytes predominate the picture, 
though a variable number of erythrocytes, as well as desquamated 
epithelial cells and bacteria are present in the fibrinous mass. 
However, notwithstanding the partial clearing of the alveoli, 
the lung is still noncrepitant, and a section of the diseased area 
will sink when placed in water. 

During the stage of resolution, if it occurs, the fluid is drained 
from the lung by the lymphatics ; the debris is removed by phago- 
cytes, and is also expectorated vrith the sputum ; and the lung 
gradually resumes its normal structure. The area of disease once 
more becomes crepitant, and a section floats when placed in 
water. 

The expectoration during the active stage of lobar pneumonia 
is thick and viscid, and of a brownish color, the so-called ''prune 
juice sputum." Frequently the viscosity is so great that the 
sputum will not separate from its container when the latter is 
inverted. 

During the inflammation of the lung in lobar pneumonia the 
pleura is practically always involved over the area of consolida- 
tion, becoming coated with a variable quantity of fibrinous exu- 
date, and not infrequently pouring out a moderate amount of 
serous fluid into the pleural cavity. However, in central pneu- 
monia, in which the consolidation is deeply situated near the root 
of the lung, the pleura escapes. It is, however, questionable 



234 PHYSICAL DIAGNOSIS 

" « 

whether lobar pneumonia ever remains central, or whether every 
lobar pneumonia which has its point of inception near the root 
of the lung eventually does not progress and involve the periph- 
ery of the lung. 

Lobar pneumonia, as the name implies, usually involves the 
major portion of a lobe or an entire lobe of the lung. The disease 
is in the majority of instances unilateral. In relative frequency 
the different portions of the lungs are involved in the following 
order: lower right lobe, lower left lobe, upper right lobe, an en- 
tire lung, or rarely both lungs. 

According to the distribution of the disease several clinical 
types of lobar pneumonia are recognized : 

Apical pneumonia affects only the apex of the lung. 

Migratory pneumonia successively involves lobe after lobe of the 
lung in regular progression. 

Doiible pneumonia involves both lungs simultaneously. 

Massive pneumonia is a form of the disease in which, in addition 
to the alveoli, the bronchial tubes of an entire lobe or lung are 
plugged with fibrinous exudate. 

Central pneumonia is a form in which the disease is situated 
deeply at the root of the lung, and does not at once involve the 
peripheral portions. 

While lobar pneumonia, under favorable circumstances, termi- 
nates in resolution with removal of the debris of the consolidation, 
the disease may terminate by sclerosis, resulting in chronic inter- 
stitial pneumonia, while in other instances the morbid process goes 
on to the formation of pulmonary abscess or gangrene. 

Physical Signs.- — Inspection. — The decubitus of the patient is 
often suggestive in lobar pneumonia. He may be found lying upon 
the diseased side or may be found sitting up in bed with the spine 
curved toward the side of the disease. Herpes labialis is a very 
common finding in lobar pneumonia; and a red spot or flush upon 
the cheek of the side of the disease is not an infrequent sign of the 
disease. The respirations are short, and are frequently accom- 
panied by an expiratory grunt. 

In a case of unilateral pneumonia, and the disease in the vast 
majority of cases is unilateral, inspection reveals restriction of the 
excursion of the thorax upon the side of the disease, with exag- 
gerated excursion of the sound side. The diseased side does not 
expand to its normal physiologic capacity for two reasons: the air 
space in the lung is actually decreased by consolidation ; and, more- 
over, the pleurisy accompanying the pneumonic process causes the 



DISEASES OF THE LUNGS 235 

patient to inhibit the respiratory movements as much as possible. 
The sound lung, on the contrary, expands vicariously in the effort 
to compensate as far as may be for the deficiency of expansion of 
the diseased lung. Litten's diaphragmatic shadow is abolished 
upon the affected side of the thorax. 

In cases in which the left lung is involved anteriorlj^, the cardiac 
impulse is frequently unduly prominent and extensive, as the por- 
tion of this lung which overlaps the heart is enlarged and more or 
less firm and is pushed forward before the heart with each impact 
of that organ during ventricular systole. 

Palpation. — Upon palpation of the thorax over the area of con- 
solidation in the stage of red hepatization vocal fremitus is mark- 
edly exaggerated. This increase of fremitus over the base poste- 
riorly, where it is usually encountered in lobar pneumonia, is very 
striking since under normal conditions of the lung, the fremitus is 
very faint in this region. The fremitus presents little alteration 
during the period of engorgement ; it reaches its maximum in- 
tensity during the stage of red hepatization; and it gradually 
resumes the normal intensity with the supervention of resolution. 

There are two conditions under which vocal fremitus is entirely 
abolished over an area of consolidation in lobar pneumonia. If the 
main bronchus leading into this area becomes plugged with fibrin- 
ous exudate, as is frequently the case in massive pneumonia, the 
vocal vibrations are not appreciable to the palpating hand. Again, 
if there be extensive involvement of the pleura with considerable 
effusion, the fluid effectually masks the otherwise palpable vibra- 
tions during phonation. 

During the stage of engorgement and the early days of the stage 
of red hepatization the pulse is full and bounding, the heart acting 
powerfully as a result of the raised blood pressure in the pulmonary 
circuit. In the later stages of the disease, in asthenic subjects, and 
when the constitutional toxemia of the disease is excessive, the 
heart is prone to undergo more or less severe parenchymatous myo- 
carditis, the pulse then becoming rapid, running, and feeble. 

Percussion. — During the period of engorgement, during the first 
twenty-four hours of the disease, percussion yields frequently 
hyperresonance of the Skodaic type. Percussion during the stage 
of red hepatization reveals dullness or flatness over the consolidated 
lobe, while percussion immediately above the consolidation, on the 
contrary, yields Skodaic resonance, due to relaxation of the tissues 
which are compressed by the consolidation. 

In a case of central pneumonia, percussion reveals only vesicular 



236 PHYSICAL DIAGNOSIS 

resonance; or, at most, only slight impairment of resonance, be- 
cause the lung immediately beneath the chest wall is not consoli- 
dated. It is here that deep percussion occasionally reveals the 
presence of the deep consolidation. During the latter portion of 
the stage of gray hepatization and during the stage of resolution, 
the lung exhibits a gradual return to the normal vesicular reso- 
nance over the area of disease. 

Ausctiltation. — During the period of engorgement the breath 
sounds are quiet and partially suppressed, while at the completion 
of full inspiration there occurs a very valuable physical sign; 
namely, a fine crepitant rale, the crepitus indux. This rale is 
produced by the separation of the walls of the infundibula, which 
have become adherent by tenacious secretion, and it presents to the 
ear of the examiner a shower of fine crackling sounds. 

When the consolidation is fully established, in the stage of red 
hepatization, the crepitus indux is replaced by distinct bronchial 
or tubular breathing. During the latter portion of the stage of 
gray hepatization and during the period of resolution, when the 
consolidation becomes macerated and partially dissolved, the bron- 
chial breath sounds are replaced by bronchovesicular breathing and 
subcrepitant rales, constituting the crepitus redux of this disease. 

The pulmonic second sound is accentuated as a result of the in- 
creased load which is thrown upon the right heart as the result of 
the obstacle which is offered to the passage of the blood through the 
pulmonary circulation. In prolonged cases of lobar pneumonia 
there is frequently a reduplication of the second sound of the heart 
due to asynchronous closure of the aortic and pulmonic valves, 
caused by the unequal tension in the general and the pulmonary 
circulations. 

Diagnosis. — In a case of frank lobar pneumonia in an adult, 
with abrupt onset with pain in the side, initial chill, and 
rapidly rising fever, coupled with the development of rusty 
tenacious sputum, the diagnosis of lobar pneumonia is not diffi- 
cult. But in young children, in the aged, in alcoholic subjects, 
and in terminal or secondary pneumonias which are engrafted 
upon other conditions as carcinoma, nephritis, or diabetes, the 
diagnosis is often reached with considerable difficulty. 

In a case of frank uncomplicated lobar pneumonia the physical 
signs are definite and distinctive ; lessened or deficient expansion 
of the diseased side of the thorax, exaggeration of vocal fremitus, 
dullness or flatness upon percussion, and bronchial breathing, with 
the crepitant rale on auscultation. But it should be borne in 



DISEASES OF THE LUNGS 237 

mind that in massive pneumonia vocal fremitus is apt to be 
diminished or abolished over the diseased area owing to plugging 
of the principal bronchus supplying the part. Moreover, in 
ordinary pneumonia, in the routine case, the dullness is preceded 
and followed by a vesiculotympanitic note, occurring prior to and 
following complete hepatization of the pulmonary tissues in the 
area of the disease. So also the bronchial breath sounds are ab- 
sent or atypical in the presence of incomplete hepatization of the 
lung, in partial plugging of a bronchus, and in the presence of a 
complicating pleurisy with effusion. Additional data for diag- 
nosis are the facts that the fever commonly terminates by crisis 
at the seventh or ninth day; that the onset is very abrupt; that 
the pulse-respiration ratio is markedly altered; that her]3es 
labialis is particularly frequent in this disease ; and that there is 
commonly a hectic flush upon the cheek upon the side of the 
disease. 

The localization of the disease in the lung is prone to influence 
the physical signs and to occasion difficulties in diagnosis. In 
massive pneumonia the ordinary physical signs are apt to be 
lacking over a large area of the lung, giving physical signs simu- 
lating pleurisy with effusion. In this class of cases it is occasion- 
ally possible to dislodge the plugging exudate by coughing. 

Central pneumonia fails to give the typical signs of frank lobar 
pneumonia. Here the lesion, starting deeply within the lung, 
overlaid as it is by normal pulmonary tissues, yields a broncho- 
vesicular respiratory murmur and only moderate impairment of 
pulmonary resonance, if indeed there is any. Deep percussion in 
these cases may serve to elicit dullness. However, as a rule, these 
cases can only be said to be central in their incipiency, as they 
usually eventuate in a peripheral lobar pneumonia involving one 
or more lobes of the lung. 

Lobar pneumonia is not infrequently a source of pain in the 
right lower portion of the abdomen, thus simulating acute ap- 
pendicitis. In other instances the disease is attended by con- 
stipation, abdominal pain and meteorism, simulating intestinal 
obstruction. In drunkards the cerebral symptoms of pneumonia 
predominate ; while in children cerebral symptoms are prominent 
and the rusty sputum is frequently absent throughout the course 
of the disease. 

Differential Diagnosis. — Lobar pneumonia must be differenti- 
ated from acute pneumonic phthisis, bronchopneumonia, pulmo- 



238 PHYSICAL DIAGNOSIS 

■ * 

nary infarction, pulmonary edema, pulmonary congestion from 
cardiac defects, and from pleurisy with effusion. 

Acute Pneumonic Phthisis. — In the early stages of the disease it is 
often impossible to differentiate between this disease and lobar pneu- 
monia. This form of pulmonary tuberculosis begins abruptly with 
chill, pain in the side, and cough which is attended by sputum 
which is at first mucoid, and later rusty. The physical signs are 
those of consolidation of one or more lobes, or possibly of an entire 
lung. The chill is followed by a rapid rise of fever, and the pic- 
ture is for a time that of frank lobar pneumonia. But at the 
seventh or ninth day no crisis occurs; on the contrary, the fever 
persists, and is attended by night sweats, while elastic fibers and 
tubercle bacilli appear in the sputum. Evidences of softening soon 
become manifest, with moist or gurgling rales and signs of cavita- 
tion. 

Bronchopneumonia. — Bronchopneumonia is usually gradual in 
onset and is usually secondary to other infectious fevers, as measles, 
influenza, scarlatina, or typhoid fever; or it occurs as the result 
of the aspiration of material from disease of the upper respiratory 
passages, or from the decomposition of the contents of bronchiec- 
tatic dilatations. 

The distribution of the disease is of assistance in differentiation, 
bronchopneumonia being bilateral, whereas lobar pneumonia, as a 
rule, affects one lobe or one lung. Moreover, the age at which the 
two diseases are most prevalent differs. Bronchopneumonia is 
most frequently encountered in young subjects, under three years 
of age frequently, whereas lobar pneumonia is more common after 
the third year and in elderly subjects. 

The physical signs of bronchopneumonia are diffuse, the patches 
of consolidation being scattered widely over both lungs, so that 
the percussion note is never frankly dull or flat, but there is bi- 
lateral impairment of pulmonary resonance of moderate degree. 
Similarly, bronchopneumonia is not attended by frank bronchial 
breathing, but by bronchovesicular breath sounds. Crisis does 
not occur in bronchopneumonia, the fever resolving by lysis. 

Pulmonary Infarction. — Infarction of the lung is abrupt in on- 
set, with dyspnea and cough; and the expectoration is not viscid, 
but is fluid and often tinged with blood or the disease is attended 
by frank hemoptysis. In simple infarction the febrile movement 
does not equal that of lobar pneumonia ; but in septic infarction a 
local pneumonia frequently develops at the site of the infarct, and 
results in pulmonary abscess with its hectic temperature and colliq- 



DISEASES OF THE LUNGS 239 

uative sweats. There are often signs of an associated valvular 
heart lesion, as the disease often occurs in persons with chronic 
endocarditis. 

Unless they are very extensive, pulmonary infarcts produce 
very few definite physical signs, though extensive infarction of 
the lower lobe of the lung produces bronchovesicular or bronchial 
breathing when properly situated with reference to a large 
bronchus. 

Pidmonary edema develops commonly in patients with valvular 
heart Jesions or nephritis, producing extreme dyspnea or orthopnea, 
with numerous moist or bubbling rales over the bases posteriorly. 
The respiratory sounds are diminished in intensity rather than 
purely bronchial. The sputum is abundant and characteristic; 
and the disease in its manifestations is bilateral, affecting the 
bases of both lungs, and it is not attended by fever. 

Pulmonary Congestion. — The variety of pulmonary congestion 
which most closely simulates lobar pneumonia is the acute active 
congestion which is described by the French authors as Woillez's 
disease, a form of active congestion of sudden onset, which really 
constitutes a larval type of pneumonia. Hypostatic congestion is 
bilateral in its manifestations, with moist rales at the bases of the 
lungs ; but there is no fever, and the sputum is not viscid or rusty. 

Serofihrmous pleurisy with effusion may be confused with lobar 
pneumonia; but there are sufficient diagnostic points to differenti- 
ate the two diseases with comparative ease. 

In pleurisy with effusion the onset is gradual, with chilly sensa- 
tions rather than abrupt with a distinct chill as in the case of lobar 
pneumonia. Pleurisy in the early stage is almost always accom- 
panied by a pleural friction sound, which disappears as the effusion 
accumulates in the pleural cavity. Pleuritic fever resolves by lysis, 
while the fever of lobar pneumonia terminates by crisis. In pleurisy 
with effusion there is often a tuberculous history obtainable in con- 
nection with the pleurisy. In pleurisy with effusion vocal fremitus 
is abolished, instead of exaggerated as is the case in lobar pneumo- 
nia. There is flatness upon percussion, whereas in pneumonia the 
note is dull or flat, but is preceded and followed by a hyperresonant 
note during the stages of incomplete hepatization. Instead of the 
crepitant and subcrepitant rales of pneumonia, in pleurisy with 
effusion there is total abolition of respiratory sounds as a rule over 
the effusion. Aspiration of the thorax reveals fluid in the case of 
pleurisy with effusion. 

Herpes labialis is rare in pleurisy, and very common in lobar 



240 PHYSICAL DIAGNOSIS 

pneumonia. Egophony may be elicited below the scapular angle 
with fair constancy in pleurisy with effusion ; and the cardiac apex 
beat is displaced to the side opposite to the effusion. The inter- 
costal spaces are more apt to be obliterated or to bulge in pleurisy 
with effusion than in pneumonia. Visceral displacement is always 
more pronounced in pleurisy than is the case with lobar pneumonia. 

BRONCHOPNEUMONIA (LOBULAR OR CATARRHAL 
PNEUMONIA) 

Clinical Pathology. — Bronchopneumonia, catarrhal, or lobular 
pneumonia is an acute inflammation of the terminal bronchioles, 
spreading secondarily to the adjacent alveoli, which become filled 
with inflammatory exudate from the terminal bronchioles. 

Bronchopneumonia is almost invariably a secondary disease, 
following many of the infectious fevers, as pertussis, measles, in- 
fluenza, diphtheria, scarlatina, variola, or typhoid fever, diseases 
which during their course have been associated with a greater 
or less degree of acute bronchitis. In these instances the develop- 
ment of bronchopneumonia merely represents a downward ex- 
tension of the acute bronchitis to the finer bronchioles, where it 
constitutes a capillary bronchitis. 

Bronchopneumonia also follows the aspiration into the bronchi 
of particles of food, or of secretions, or of blood from the upper 
respiratory passages (aspiration or deglutition pneumonia). In 
apoplexy, and during comatous states from other causes, particles 
are prone to be aspirated into the bronchi and to set up a broncho- 
pneumonia. Aspiration pneumonia occurring in the newly born 
is due to the aspiration of secretions from the birth canal during 
labor. 

Bronchopneumonia is very common in infancy, attacking many 
children under one year of age. In this class of patients the pres- 
ence of rickets or severe diarrhea predisposes to the development of 
the disease. 

A primary bronchopneumonia occasionally develops in adults 
and children who are below par, in which the onset of the disease 
is abrupt, simulating in this respect lobar pneumonia. 

The organisms which are most frequently responsible for bron- 
chopneumonia are Friedlander's bacillus and the pneumococcus of 
Fraenkel. These organisms may occur alone or in association with 
the streptococcus, influenza bacillus, colon bacillus, or staphylococ- 
cus. 



DISEASES OF THE LUNGS 241 

In bronchopneumonia the lung presents upon its surface scat- 
tered patches of consolidation, which are separated by areas of 
compensatory emphysema. The consolidated patches are red or 
grayish, and slightly elevated above the surrounding surface of the 
lung. The disease is bilateral, affecting both lungs, which remain 
crepitant despite the multiple areas of consolidation, and the lung 
will float when it is placed in water. 

When the lung is sectioned, the pneumonic patches of consolida- 
tion are observed to be situated in and confined to the peripheral 
portions of the lung, just subjacent to the pleura. 





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Fig. 106. — Consolidation of bronchopneumonia. (From Delafield and Prudden.) 

The terminal bronchioles are filled with mucopurulent exudate ; 
while the peribronchial tissues are consolidated in the immediate 
vicinity of the bronchus, and exhibit splenization for some distance 
beyond the area of consolidation. Microscopically the bronchial 
walls present swelling and desquamation of the lining cells, while 
the bronchial lumen is filled with mucopurulent exudate, composed 
mainly of desquamated bronchiolar cells and with very few erythro- 
cytes and leucocytes. The bronchial walls and interalveolar septa 
in the consolidated areas show infiltration with leucocytes. 

The distribution of the disease varies. As the name implies, the 
disease has a tendency to involve lobules rather than lobes of the 
lung. As a rule, this principle holds true in the distribution of the 
lesions, which usually assume one of two types. Thus, in the dis- 



242 Physical diagnosis 

seminated form of bronchopneumonia lobules are consolidated 
throughout the two lungs, the areas of consolidation being sepa- 
rated by areas of crepitant lung. In the pseudolobar form, how- 
ever, a number of lobules in one lobe are consolidated, perhaps 
affecting the greater portion of a lobe of the lung. 

Bronchopneumonia may terminate in resolution, in abscess, in 
fibrosis, or in gangrene. In the cases which terminate by resolu- 
tion the cellular exudate in the bronchioles and alveoli becomes 
liquefied, largely as a result of fatty degeneration, and is borne 
away by the lymphatics or is expectorated. 

The pleura is frequently involved in bronchopneumonia, but not 
to the same degree as in lobar pneumonia; but when pleurisy 
develops with bronchopneumonia it is very apt to be of the purulent 
type. 

The expectoration in bronchopneumonia is tenacious and glairy, 
containing no characteristic elements. 

Physical Signs. — Inspection. — Bronchopneumonia is constantly 
attended by signs of obstruction of the terminal bronchioles, as 
evinced by inspiratory dyspnea, with participation of the acces- 
sory muscles of respiration and inspiratory retraction of the lower 
intercostal spaces and epigastrium. In infancy and childhood 
there is frequently cyanosis of the mucous membranes and ex- 
tremities, with suffocative attacks; and in infancy the disease is 
occasionally ushered in with convulsions. In the fully established 
case of bronchopneumonia the thoracic expansion is bilaterally re- 
stricted ; and, moreover, in instances of extensive consolidation 
of the bases the upper portion of the thorax exhibits a greater de- 
gree of expansion than does the lower portion. Atelectasis of the 
anterior border of the left lung, which overlies the heart, results in 
a cardiac impulse of increased extent, whereas compensatory em- 
physema of the left pulmonary borders causes a corresponding 
diminution in the area of cardiac pulsation in other cases. 

Palpation. — Palpation reveals increase of vocal fremitus when 
there is a patch of consolidation of suffi^cient size and favorably 
situated with reference to a bronchus. However, the intervening 
emphysematous portions of the lung tend to mask the fremitus, 
which may be actually diminished. Similarly, occlusion of a bron- 
chus by exudate may abolish the fremitus. In the pseudolobar 
form of the disease there is invariably increase of vocal fremitus, 
whereas in the disseminated form such an increase is not to be 
expected. 

During the early stage of the disease the pulse rate is accelerated. 



DISEASES OF THE LUNGS 243 

with full volume and normal rhythm. During the late stage of the 
disease, in unfavorable cases, the rhj^thm of the pulse is disturbed, 
the pulse becoming rapid, readily compressible, and often dicrotic. 

Percussion. — In bronchopneumonia during the first twenty-four 
hours of the disease, percussion of the thorax elicits only normal 
pulmonary resonance ; but in a suspected case the bases posteriorly 
should be percussed daily ; and in most instances at the expiration 
of forty-eight hours one or more areas of dullness will have become 
demonstrable in these regions. However, the thorax of the young 
child, in whom the disease is frequently encountered, is normally 
slightly hyperresonant ; and, moreover, the areas of compensatory 
emphysema, which surround and separate the patches of consoli- 
dation, tend to mask any dullness which would be produced by the 
presence of the consolidated areas, and to impart a vesiculotym- 
panitic quality to the percussion note. In the disseminated form 
of bronchopneumonia frank dullness is not to be expected, as the 
hyperresonance of the associated compensatory emphysema effectu- 
ally masks the dullness of the consolidation. In the pseudolobar 
form, on the contrary, dullness may always be elicited by careful 
daily percussion of the bases posteriorly. In demonstrating the 
dullness of superficial patches of consolidation it is essential to 
employ very light superficial percussion; while in eliciting the 
dullness of deeply seated areas of solidification more forcible, deep 
percussion should be employed. 

Percussion of the anterior portion of the thorax in the infra- 
clavicular and mammary regions yields Skodaic resonance. The 
presence of bilateral dullness over the bases posteriorly with 
Skodaic resonance anteriorly is very suggestive of the consolidation 
of bronchopneumonia. 

Auscultation. — Auscultation reveals upon consecutive examina- 
tions the downward extension of the original bronchitis. In addi- 
tion to the rales arising in the bronchial tubes incident to the 
bronchitis, the crepitant rale is audible upon the completion of 
inspiration over the bases posteriorly, indicating the participation 
of the alveoli in the inflammatory process. At times the rales are 
obscured by plugging of the bronchioles by inflammatory exudate ; 
but coughing usually serves to bring them again to the fore. 

As the patches of consolidation form, the respiratory sounds 
assume a bronchovesicular character ; but they never become purely 
bronchial as is the case in lobar pneumonia. The pulmonic second 
sound is accentuated during' the height of the disease: and if the 



244 PHYSICAL DIAGNOSIS 

■ * 

right heart fails, edema of the lungs supervenes, with the character- 
istic signs of that condition. 

In the presence of considerable consolidation of the bases, bron- 
chophony is occasionally to be elicited just above the level of the 
consolidation. Over the anterior surface of the thorax, in the 
region of compensatory emphysema, the expiratory murmur is 
slightly prolonged, and is accompanied by piping, sibilant rales. 

Diagnosis. — While the physical signs of bronchopneumonia are 
bilateral in distribution, they are seldom present to the same 
degree upon both sides of the thorax, one lung usually being in- 
volved to a greater extent than is the other. Whenever physical 
signs of consolidation are elicited over one lung, a careful search 
for similar signs should be made over the opposite lung. 

Very frequently a diagnosis of bronchopneumonia cannot be 
made upon the physical signs alone, as these are often misleading ; 
and as the mode of onset of the disease is not infrequently atypi- 
cal. The physical findings should be considered in conjunction 
with the fever, cough, dyspnea, and pain in the thorax, arising 
during the course of an acute infectious disease, or engrafted 
upon a previously existing acute bronchitis. Moreover, occurring 
as the disease does during the course of, or convalescence from, 
another acute disease, the clinical picture is often modified for a 
time at least by the characters of the primary affection. But a 
history of fever, with dyspnea, cough, and pain in the chest, 
arising during the course of an acute infection or engrafted upon 
a previous bronchitis is suggestive of a complicating broncho- 
pneumonia. 

Differential Diagnosis. — From acute bronchitis the disease is 
differentiated by the absence of areas of hyperresonance and im- 
paired resonance in the former, and by the finer quality of the 
rales in bronchopneumonia. Moreover, in acute bronchitis there 
is little or no fever, and the disease is altogether milder in its 
manifestations. 

From loljar pneumonia, bronchopneumonia presents many points 
of differentiation. Bronchopneumonia is usually secondary to 
another disease and is of insidious onset ; whereas lobar pneumonia 
is usually a primary disease, with abrupt onset and stormy course. 
Moreover, bronchopneumonia is a bilateral pulmonary disease, pro- 
ducing multiple areas of impaired resonance over both lungs, 
rather than a single area of dullness or flatness over one or more 
lobes of a lung. Also, the fever of bronchopneumonia terminates 
gradually by lysis, whereas that of lobar pneumonia terminates by 



DISEASES OF THE LUNGS 245 

crisis between the seventh and the ninth days in the majority of 
cases. As a rnle, bronchopneumonia attacks subjects of impaired 
vigor who are below par physically, whereas lobar pneumonia 
frequently attacks robust persons in the prime of health. 

In the rarely encountered primary form of bronchopneumonia, 
and in those cases in which the disease assumes the pseudolobar 
form, in which the pneumonic patches fuse and involve the greater 
portion of a lobe of the lung, the differentiation from lobar pneu- 
monia is attended with considerable difficulty. In this class of cases 
the physical signs are very similar if not identical ; but in broncho- 
pneumonia there is almost invariably apparent, even if to a slight 
degree, some involvement of the opposite lung. Moreover, in lobar 
pneumonia the sputum is fairly characteristic, differing markedly 
from the viscid, glairy expectoration of bronchopneumonia. 

From acute hronchopneumonic phthisis, bronchopneumonia can- 
not be differentiated in the incipient stage. Involvement of the 
apices by the disease is suggestive of phthisis; but in certain cases 
of bronchopneumonic phthisis the apical involvement is not par- 
ticularly prominent. However, in phthisis the temperature is 
prone to remain more uniformly high, and to be interrupted early 
in the course of the disease by night sweats. There is usually ob- 
tainable a history of intimate association with a tuberculous person 
or evidence of a tuberculous focus at some point. Moreover, in 
acute bronchopneumonic phthisis emaciation progresses rapidly, 
the course of the disease being progressively downward, until 
eventually tubercle bacilli are demonstrable in the sputum. 

Bronchopneumonia in infancy is sometimes with difficulty differ- 
entiated from meningitis, as the disease in this class of patients is 
often accompanied by marked cerebral symptoms, as delirium or 
convulsions. Time and observation are essential to a differential 
diagnosis under these circumstances. 

CHRONIC INTERSTITIAL PNEUMONIA (PRODUCTIVE 

PNEUMONIA; CIRRHOSIS OR FIBROSIS OF 

THE LUNG) 

Clinical Pathology. — Chronic interstitial pneumonia, produc- 
tive pneumonia, cirrhosis or fibrosis of the lung, is a chronic in- 
durative pulmonary disease, the ultimate result of continued 
irritation of various areas of the lung. The predominant feature 
of the disease is the formation of an excess of fibrous connective 



246 



PHYSICAL DIAGNOSIS 



tissue, which by subsequent contraction decreases the size and 
the vital capacity of the lung. 

Chronic interstitial pneumonia occurs in three forms; namely, 
the massive or lobar form; the insular, or hronchopneumonic form; 
and the pleurogenous form of the disease. To these three principal 
groups may be added the cases of local or circumscribed pulmonary 
fibrosis, which result from the inhalation of irritant dusts, or which 
develop in the evolution of pulmonary tuberculosis and syphilis 
of the lung. 

The massive or lobar form of the disease is almost invariably a 





















W 






Ml 










Fig. 107. — Interstitial pneumonia with emphysema. (From Delafield and Prudden.) 



unilateral affection, involving the lower lobe to a greater degree 
than the upper lobe of the lung. In the rarer instances of bilateral 
involvement the induration is much more pronounced in one lung 
than in its fellow. Massive chronic interstitial pneumonia occurs as 
a result of incomplete resolution after lobar or after bronchopneu- 
monia ; as a terminal change in extensive atelectasis ; and occasion- 
ally as a result of prolonged compression of the lung by chronic 
pleural effusion. In this form of the disease the pleura is but 
slightly involved. The interalveolar septa are greatly thickened 
by the formation of an excess of fibrous connective tissue, and the 
alveoli are reduced in size. 



DISEASES OF THE LUNGS 247 

In the insular or hronchopneumonic form of the disease the 
induration has its inception as a peribronchial fibrosis, involving 
principally the lower lobe, though the upper lobe is not infre- 
quently involved as well. By traction of the fibrous bands bron- 
chiectatic dilatations of variable dimensions are produced during 
the evolution of the disease. 

Pleiirogenous interstitial pneumonia develops as a consequence 
of pulmonary compression by chronic pleural effusion. The 
pleura is excessively thickened, and fibrous bands pass from the vis- 
ceral pleura along the interalveolar septa to the bronchi in the 
deeper portions of the lung. 

The ultimate result of chronic pulmonary fibrosis is very sim- 
ilar in the three types of the disease. The indurated lung is 
shrunken, hard, and diminished in size, occupying a position in 
the upper portion of the pleural cavity near the vertebral column. 
Dense adhesions are apt to form between the visceral and pari- 
etal pleurae, binding the lung to the chest wall. Upon section, 
bronchiectases of variable dimensions are encountered, in various 
stages of evolution, ulceration, or abscess formation. 

Physical Signs. — Inspection. — In chronic interstitial pneumonia 
the thorax upon the side of the disease is restricted in its expan- 
sion, and occasionally it is immobile during the respiratory ex- 
cursion of the opposite side. Retraction of the side with drooping 
of the shoulder is noted in advanced cases of the disease. The 
cardiac impulse is displaced toward the affected side; and when 
the disease attacks the left lung there is not uncommonly a very 
wide area of pulsation in the third and fourth interspaces. As a 
result of the retraction of the diseased side, the nipple and the 
scapula approach more nearly to the median line than is normal. 
The spinal processes present lateral curvature, with the concavity 
directed toward the side of the cirrhotic lung. 

In cirrhosis of the right lung the cardiac impulse is frequently 
invisible, as it is not infrequently displaced so far toward the 
right as to lie behind the sternum. Even in those cases in which 
the right-sided cirrhosis is not so great as to displace the impulse 
behind the sternum, the apex-beat may yet be invisible owing to 
overlapping of the apex of the heart by the compensatorily 
emphysematous left lung. 

Palpation. — In the vast majority of cases of chronic interstitial 
pneumonia A^ocal fremitus is exaggerated upon the side of the 
disease, although in cases of pleurogenous origin which are asso- 
ciated with excessive pleural thickening, it may be diminished. 



248 PHYSICAL DIAGNOSIS 

■ « 

In these cases a pleural friction fremitus can occasionally be 
detected upon palpation. Vocal fremitus is very greatly in- 
creased when a large bronchial dilatation approaches the chest 
wall, which occurs most frequently in the axillary region. 

Percussion. — As a rule, percussion of the thorax over the area 
of the retracted lung yields a dull or flat note ; but percussion of 
the upper axillary region in many instances yields tympany due 
to the close proximity to the chest wall of a bronchiectasis. Per- 
cussion of the sound lung yields a moderately hyperresonant 
note, as the result of compensatory emphysema. The superior 
limit of pulmonary resonance is diminished on the side of the dis- 
ease as a result of retraction of the apex of the lung. Similarly, 
in involvement of the right lung the lower border of pulmonary 
resonance is elevated, the liver pushing the diaphragm upward; 
whereas in left sided disease the tympany of Traube's semilunar 
space extends to an abnormally high level. 

Auscultation. — Auscultation of the affected side reveals bron- 
chial breathing over the retracted and shrunken lung, which, over 
dilated bronchi or bronchiectatic cavities, frequently has an am- 
phoric or cavernous quality engrafted upon it. Over the lower 
portion of the thorax of the affected side, and in cases which are 
associated with excessive pleural thickening, the respiratory mur- 
mur is distant or is entirely abolished. Over the pulmonary apex 
and in the axillary region, where the bronchial dilatations are 
apt to approach most nearly to the chest wall, the respiratory 
murmur is bronchial or amphoric. Over the sound lung the res- 
piration is puerile as the result of compensatory emphysema. In 
cases of pleurogenous origin a pleural friction sound is frequently 
audible over the cirrhosed lung. 

The pulmonic second sound is accentuated; and late in the 
course of the disease is apt to become weakened, the tricuspid 
systolic "safety-valve" murmur then becoming audible, betokening 
imminent right heart failure. 

Diagnosis. — In a subject presenting unilateral retraction of 
the thorax with drooping of the corresponding shoulder and signs 
of pulmonary collapse of extensive duration, following pneu- 
monia or chronic serofibrinous pleurisy, chronic interstitial pneu- 
monia is suggested. Early diagnosis of the disease is rendered 
difficult by the fact that limited areas of fibrosis, whether situated 
peripherally or centrally, yield few physical signs. A slowly 



DISEASES OF THE LUNGS 249 

growing neoplasm of the lung or jDleura closely simulates the 
physical signs of chronic interstitial pneumonia. 

It is to be borne in mind that the physical signs of fibroid 
phthisis are very similar to those of chronic interstitial pneu- 
monia. In phthisis, however, the disease is more frequently 
bilateral, and the persistence of moist rales at an apex speaks 
for phthisis. The detection of the tubercle bacillus in the sputum 
is in the end the deciding factor in the differential diagnosis of 
the two diseases. 

TUBERCULOSIS OF THE LUNGS 

In the inciaence of pulmonary tuberculosis the tubercle bacil- 
lus may reach the lung directly through the inhalation of the 
dried sputum of a tuberculous patient or by droplet infection. 
A break in the continuity of the mucous membrane of the res- 
piratory tract is not essential for infection with the tubercle 
bacillus; but catarrhal inflammation of the air passages predis- 
poses to infection with the organism. 

Aside from direct, aerial infection, pulmonary tuberculosis 
has followed the ingestion of infected food. In this method of 
infection it is possible that the bacilli are absorbed through the 
tonsils, passing primarily to the cervical lymph nodes ; but in 
the majority of instances the organisms reach the intestine, 
whence they pass through the mucous membrane and enter the 
lymphatics which form the radicles of the thoracic duct, ulti- 
mately reaching the blood stream and causing general infection 
with the tubercle bacillus. 

Eace, social environment, and the state of health of the indi- 
vidual all influence the incidence of pulmonary infection with the 
tubercle bacillus. The American Indian and the Negro exhibit 
a marked susceptibility to pulmonary tuberculosis, though in the 
latter race it is difficult to separate the racial predisposition to 
the disease from the effects of social environment. Doubtless 
the most important single contributing factor is that of the en- 
vironment in any case, a factor which accounts in many instances 
for the so-called family predisposition to the disease. Catarrhal 
inflammation of the respiratory tract incident to pneumonia, per- 
tussis, measles, and influenza predispose to infection with the 
tubercle bacillus; whereas constitutional diseases, as diabetes 
mellitus and symptomatic anemia, render the patient also more 



250 PHYSICAL DIAGNOSIS 

■ * 

subject to the disease. Aside from the production of a soil which 
is favorable for the growth of the organism, these diseases are 
apt to call into activity a latent or residual tuberculous lesion of 
the lung. 

The primary lesion of pulmonary tuberculosis is a minute, 
grayish mass of inflammatory tissue, the miliary tubercle. By the 
growth of the miliary tubercle and by the coalescence of adjacent 
tubercles more extensive areas of tuberculous infiltration and con- 
solidation arise within the pulmonary tissues. As a result of the 
histological structure of the tubercle, as the mass extends by 
peripheral groAvth, the central portion, representing the original 
tul)ercle, becomes ischemic and tends to undergo softening and 
caseation. The usual termination of an area of caseation is 
pulmonary excavation, containing caseous material which, by 
admixture with serum, constitutes the so-called tuberculous pus. 
In rare instances a focus of softening is replaced by fibrous tissue, 
constituting '^healing by sclerosis." 

When a tuberculous focus is established in the lung its ten- 
dency is almost invariably toward progressive extension. When 
the bronchial tubes are involved, a tuberculous chronic bronchitis 
ensues, and infective material is conveyed to adjacent portions 
of the lung by the propulsive action of the inspired and expired 
air during respiration. The infection also progresses by con- 
tinuity of the pulmonary tissues, the infective focus progressively 
involving adjacent lobules of the lung. The infective organism 
is also disseminated by the medium of the pulmonary lymphatics 
and by the blood stream. During the evolution of the tubercle 
a vein is apt to be eroded and the bacilli widely disseminated 
throughout the lung and indeed throughout the general circula- 
tion. Infection of an entire lung is usually explained in this Avay. 

The initial lesion of pulmonary tuberculosis develops in the 
vast majority of cases in the apical portion of the lung. The 
apparent predilection of the tubercle bacillus for this portion of 
the lung is probably due to the fact that the apices of the lungs 
are less mobile than are the bases, resulting in a relative retarda- 
tion of the flow of blood and lymph in this region, which favors 
infection with the tubercle bacillus. 

Pulmonary tuberculosis occurs in four forms; namely, acute 
miliary tuberculosis; acute tuherculo-pneumonic phthisis, of which 
there are two varieties, the pneumonic, and the hroncliopneumonic; 
chronic idccrative phthisis ; and fihroid phthisis. 



DISEASES OF THE LUNGS 251 

ACUTE MILIARY TUBERCULOSIS OF THE LUNGS 

Clinical Pathology.— This form of pulmonary tuberculosis re- 
sults from the erosion of a vein by a tuberculous focus, where- 
upon the bacilli are distributed throughout the lungs and by way 
of the blood stream to various organs of the body. The disease 
has not infrequently followed attacks of pertussis and measles 
during childhood. For a time following the erosion of the vessel 
and the dissemination of the organisms through the body the 
subject of the disease presents the picture of an acute generalized 
infection with hepatic and splenic enlargement. After a variable 
period the symptoms and signs become localized in the broncho- 
pulmonary system, and the lungs upon autopsy are found studded 
with innumerable miliary tubercles, while the bronchi and bronchi- 
oles are the seat of a tuberculous bronchitis. 

Physical Signs.— Inspection. — The physical signs of acute 
miliary tuberculosis of the lungs are in the main those of acute 
catarrhal bronchitis, with, however, a more extreme grade of 
dyspnea, cyanosis developing upon very slight exertion. Cough 
is persistent, and is attended by the raising of mucopurulent 
sputum, which early in the course of the disease becomes sanguin- 
eous, with the coincident presence of tubercle bacilli. 

Palpation. — Palpation of the thorax in acute miliary tubercu- 
losis seldom yields any diagnostic data. The pulse is unduly ac- 
celerated from the onset of the disease, frequently exceeding 160 
beats per minute. Palpation of the spleen reveals enlargement of 
that organ. 

Percussion. — In acute miliary tuberculosis of the lungs the find- 
ings upon percussion of the thorax are variable. As a rule, the note 
is moderately hyperresonant, despite the wide dissemination of 
miliary tubercles throughout the lungs. In the case of children, 
in whom the disease has arisen as a sequela of measles or pertussis, 
the percussion findings are very similar to those of nontuberculous 
bronchopneumonia, with scattered areas of dullness over the bases 
and Skodaic resonance in the infraclavicular and mammary re- 
gions. In cases which are attended by pleural effusion dullness or 
flatness is elicited over the dependent portions of the lungs. 

Auscultation. — Moist rales are demonstrable over both lungs, be- 
coming more numerous and assuming the mucous type toward the 
termination of the disease. Pleural friction is occasionally en- 
countered ; and Jiirgensen has described a fine crepitation which 
is caused by the presence of miliary tubercles upon the pleura. In 



252 PHYSICAL DIAGNOSIS 

■ * 

children the breath sounds over the bases posteriorly are often 
bronchovesicular or even frankly bronchial in type. 

Diagnosis, — The extreme degree of dyspnea and cyanosis upon 
the slightest exertion serve to place the disease above the signs of 
a simple catarrhal bronchitis of nontuberculous origin. In chil- 
dren it is difficult for a time to differentiate the disease from a 
nontuberculous bronchopneumonia. "When, however, the sputum 
becomes sanguineous and when tubercle bacilli are detected in the 
expectoration, the differential diagnosis is plain. In the adult 
subject the progressive downward course of the disease and the 
failure of the fever to terminate by crisis serve to eliminate the 
possibility of lobar pneumonia. 

ACUTE PNEUMONIC PHTHISIS 

Clinical Pathology. — In acute pneumonic phthisis the disease 
involves the greater portion of a lobe, or indeed an entire lung, 
the morbid process having its inception in a tuberculous focus in 
one apex. This form of phthisis attacks males with greater fre- 
quency than females, and the subjects of the disease frequently 
have been in robust physical condition until the inception of the 
disease. Exposure to the elements is not infrequently the imme- 
diate precursor to the onset of the acute symptoms, while in 
other instances the disease develops during convalescence from 
an attack of influenza or other acute infectious disease. 

During the early stage of the disease the alveoli are the seat 
of dense consolidation which resembles that of lobar pneumonia 
during the stage of hepatization. In the further evolution of the 
disease, excavation of the lung ensues with cavity formation. 
The pleura corresponding to the area of pulmonary disease is 
inflamed, and is clothed with a variable amount of fibrinous 
exudate. 

The sputum, which is at first scanty and mucoid, becomes 
abundant and serosanguineous, containing elastic fibers and tu- 
bercle bacilli. The latter are occasionally demonstrable in the 
sputum during the first week of the disease. 

Physical Signs. — The physical signs of acute pneumonic phthi- 
sis correspond in the main to those of lobar pneumonia, with cer- 
tain differences in the area of distribution of the principal signs 
of the diseases. 

Inspection. — Respiration is rapid and labored, and occasionally 
the disease is attended by repeated attacks of imminent suffocation. 



DISEASES OF THE LUNGS 



253 



with cyanosis. The cheeks commonly wear a hectic flush ; and 
herpes labialis, which is so frequently observed in lobar pneumonia, 
is only occasionally noted in acute pneumonic phthisis. 

Palpation. — Vocal fremitus is exaggerated over the consolidated 
area, which usually occupies the apex or upper lobe of one or both 




F:g. 108. — Illustrating caseous tuberculosis. Large cavities at the apex and many small 
cavities throughout the lung. (Pottenger, after Tendeloo.) 



lungs. Palpation of the supraclavicular regions during inspiration 

reveals deficient inspiratory expansion of the apices of the lungs. 

Percussion. — Percussion of the thorax during the first few days 



254 PHYSICAL DIAGNOSIS 

■ » 

of the disease reveals normal resonance, or indeed, a slightly hyper- 
resonant note, which early is succeeded by dullness due to consoli- 
dation. Late in the course of the disease, after cavitation has 
supervened, the note changes again and it is possible in many in- 
stances to elicit one or more of the classical signs of cavity. 

Auscultation. — The earliest auscultatory findings are a partial 
suppression of the vesicular murmur, which later in the evolution 
of the disease becomes bronchovesicular or purely bronchial in 
character. This purely tubular breathing persists for a week or 
ten days, when, instead of clearing and disappearing as is the case 
in lobar pneumonia, signs of cavity formation, indicating softening 
and excavation of the lung, supervene. 

Diagnosis. — Acute pneumonic phthisis must be differentiated 
from lobar pneumonia, which it closely resembles during the 
early stages. However, it is to be remembered that phthisis is 
prone to have its inception in the apices while lobar pneumonia is 
prone to involve the base of the lung. Moreover, at the seventh 
or ninth day, instead of terminating by crisis with amelioration 
of the more acute symptoms, the disease progresses and pursues 
an aggravated course, with sweats, and the appearance of elastic 
fibers and tubercle bacilli in the sputum. Moreover, in the case 
of phthisis the opposite lung is apt to yield similar physical signs, 
though to a minor degree ; and it is occasionally possible to obtain 
a history of previous tuberculosis in the subject. 

ACUTE BRONCHOPNEUMONIC PHTHISIS 

Clinical Pathology .^Acute bronchopneumonic phthisis, '^ phthi- 
sis florida," or ^'galloping consumption," is most frequently 
observed in children, in whom it arises as an independent affec- 
tion, but with far greater frequency as a sequela of one of the 
acute infections, notably after measles and pertussis. With less 
frequency the disease attacks adults, and not infrequently those 
who are in the prime of health. 

The disease is a caseous bronchopneumonia, with its point of 
inception in the terminal bronchioles, which early become oc- 
cluded by a caseous material, while the alveoli are filled with the 
products of an acute catarrhal pneumonia. The areas of con- 
solidation are as a rule widely disseminated throughout the upper 
lobes of the lungs. By fusion of adjacent areas of consolidation, 
almost an entire lobe may become airless ; .but in most instances 



DISEASES OF THE LUNGS 255 

the patches of consolidation are separated by bands of crepitant 
pulmonary tissue. 

Physical Signs. — Inspection. — The subject of bronchopneumonic 
phthisis is liable to attacks of extreme dyspnea and cyanosis, with 
cough, progressive emaciation, and hectic flushing of the cheeks. 
As the disease progresses, the patient becomes dull and somnolent, 
with dry lips and tongue, and a general appearance of torpor. 

Palpation. — Palpation frequently reveals exaggeration of vocal 
fremitus in the infraclavicular and mammary regions, and palpa- 
tion of the supraclavicular fossae shows lagging expansion of the 
apices during inspiration. 

Percussion. — The note upon percussion is seldom frankly dull. 
Rather it has a vesiculotympanitic quality, owing to the presence 
of multiple patches of consolidation separated by areas of crepitant 
lung. 

Auscultation. — The respiratory murmur over the areas of con- 
solidation is bronchovesicular, not attaining to the purely bronchial 
type, with crepitant and subcrepitant rales. Late in the disease, 
with the supervention of softening and cavitation, amphoric or 
cavernous breathing is apt to be encountered. 

Diagnosis. — Acute bronchopneumonic phthisis must be differ- 
entiated from nontuberculous bronchopneumonia, a problem 
which requires time and observation of the patient. A broncho- 
pneumonia which has its inception in the apices is strongly sug- 
gestive of phthisis. The rapid emaciation of the subject points to 
the same origin of the disease ; while with the detection of signs of 
pulmonary excavation and with the advent of the tubercle bacil- 
lus in the sputum, the diagnosis is assured. 

CHRONIC ULCERATIVE PHTHISIS 

Clinical Pathology. — Chronic ulcerative phthisis has its incep- 
tion in a tuberculous focus in one or both apices and the disease 
extends progressively downward, involving lobule after lobule, 
and lobe after lobe of the lung. From an apical lesion infective 
material is aspirated into the bronchial tubes of uninfected por- 
tions of the lung and here sets up tubercle formation about the 
finer bronchioles. Thence the disease spreads to the infundibula, 
and with less frequency, ascending infection occurs, leading to 
infection of the bronchi immediately above the smaller bronchi- 
oles. 

The infective process also travels by continuity of tissue from 



256 



PHYSICAL DIAGNOSIS 



a primary focus to the immediately surrounding portions of the 
lung. Infection frequently travels by the lymphatics or the 
blood stream, infecting other portions of the lung. Through 




Fig. 109. — Illustrating pulmonary tuberculosis, with thickened pleura, many bronchiectatic 
cavities, and generalized cavity formation. (Pottenger, after Tendeloo.) 

these avenues the infection of the lung Avhen once established, 
progressively attacks the several portions of the lung. 

In the further evolution of the disease different portions of the 



DISEASES OF THE LUNGS 257 

lung show tubercles in different stages of infiltration, caseation, 
or softening, leading eventually to cavity formation. Ulceration 
of the walls of the bronchial tubes not infrequently permits 
stretching of these walls during paroxysms of cough or from the 
weight of stagnant secretion, with the formation of bronchiec- 
tatic dilatations. 

Aside from the bronchiectatic cavities, excavation of the lung 
occurs apart from the bronchi. The walls of these cavities in cer- 
tain instances are smooth, while in other cases they are uneven 
and rugged. In these cavities blood vessels which have not been 
destroyed may be found traversing the cavities ; and by rupture 
they may produce copious hemorrhage, which may prove fatal. 
Cavities of moderate size by coalescence often lead to the forma- 
tion of extensive excavations, which, in exceptional instances may 
embrace the greater portion of a lobe of the lung. The cavities 
of chronic ulcerative phthisis occur with great frequency in the 
upper lobe of the lung, whereas the cavity which is of bronchi- 
ectatic origin is commonly situated in the lower lobe. 

When the peripheral portions of the lung are involved, a cavity 
is apt to form immediately subjacent to the pleura, and by rup- 
ture through that membrane is apt to produce pneumothorax. In 
other instances, instead of rupturing with the formation of a 
fistulous communication between the lung and the pleural cavity, 
adhesions may form between the visceral and the parietal pleura 
as the result of localized pleurisy overlying the tuberculous lesion 
of the lung. These pleural adhesions are frequently quite ex- 
tensive, to a great extent serving to immobilize the lung. 

Instead of undergoing caseation and softening with consequent 
cavity formation, tuberculous foci in the lung may undergo a 
process of sclerosis. Sclerosis is a reparative process, tending to 
inhibit the spread of infection; but it is uncommon for sclerosis 
to occur to an extent which is sufficient to save a tuberculous 
lung. Lime salts may be deposited in sclerotic and caseous foci 
and limit the spread of the infection temporarily; but an attack 
of a bronchial affection such as influenza is prone to ''light up" 
these dormant or residual foci of infection. 

The bronchial glands do not escape the tuberculous infection. 
Infiltration, caseation, abscess formation, and rupture of the glands 
are frequently encountered. 

Physical Signs. — The physical manifestations of chronic ulcera- 
tive phthisis are variable, depending upon the duration and the 
progress of the individual case. All gradations are encountered, 



258 



PHYSICAL DIAGNOSIS 



from the incipient case with few definite physical signs to the ad- 
vanced case with the characteristic deformity of the thorax and 
the distinctive hall marks of the disease. 























































'.:^K 








mi 


!^ 






1 


HP 








. 



Fig. 110. — Roentgenogram. The special features of this picture are the prominent 
bronchi, showing induration; the diffuse shadows throughout the lungs, indicating tuber- 
culosis; small tent-like raised areas in the diaphragm, indicating pleural adhesions and 
the large right heart. (From Brown.) 

Inspection. — The incipient case of chronic ulcerative phthisis 
occasionally presents the classical phthisical thorax; but this is 
by no means uniformly present at this early stage of the disease. 



DISEASES OF THE LUNGS 



259 



A more frequent anatomic change consists in moderate flattening 
of the thorax, together with supraclavicular depressions of un- 
equal depth. Also there is lagging expansion at one apex, which 
is often so slight as to require palpation of the supraclavicular 
area for its detection. Moderate pallor of the skin and mucous 




Fig. 111. — Lung. Chronic phthisis, showing a large irregular cavity in the upper lobe. 
In the lower lobe there are scattered acute nodules grouped in clusters around the small 
bronchi; and also several small more acute cavities. The bronchial glands are enlarged 
and caseous, (l^dinburgh University Anatomical Museum.) (Woolley after Beattie and 
Dickson.) 



260 



PHYSICAL DIAGNOSIS 



membranes is often in evidence. Many subjects of incipient phthi- 
sis exhibit an abnormal flattening and mobility of the sternal 
angle (Rothschild's sign) ; while in other cases there is early 
ankylosis and preternatural rigidity of the vertebral column in 
the thoracic region (Lorenz's sign). 

In advanced cases of chronic phthisis the phthisical or alar 
thorax is in evidence, with undue prominence of the bony thorax 
and atrophy of the soft structures. Unilateral deficiency of 
expansion is noted, most markedly in the infraclavicular and 
mammary regions. In the very late case the thorax frequently 




Fig. 112. — Illustrating compensatory change in right lung with depression of the dia- 
phragm following extensive cavitation of left lung. 



exhibits bilateral deficiency of expansion, the principal respira- 
tory movement of the thorax occurring in a vertical direction. 
In the presence of advanced tuberculosis of the left lung the heart 
exhibits a wide impulse in the third and fourth interspaces. In 
not a few instances the pupil corresponding to the side of the 
principal pulmonary disorganization is dilated as a result of pres- 
sure exerted upon the cervical sympathetic fibers. In cases of 
extreme unilateral disease the vertebral column is bowed with the 
concavity directed toward the side of the disease. Loeal retraction 
of the chest wall is frequently to be noted, indicating areas of pul- 



DISEASES OF THE LUNGS 261 

monary collapse or the traction of pleural adhesions. The fingers 
are often Hippocratic, presenting clubbing of the terminal pha- 
langes. 

As the disease progresses, dyspnea becomes a prominent feature 
of the picture, partially as a result of pulmonary excavation, and 
partially as a consequence of the development of emphysema ; 
and late in the course of the disease as a manifestation of right 
heart failure. Coincidentally the pallor of the skin and mucous 
membranes increases; the skin of the thorax is apt to present 
patches of yellowish-brown pigmentation ; and, as the right heart 
fails, edema of the feet and ankles develops rapidly. 

The sputum is characteristic of the disease. Scanty and almost 
purely mucoid in the early stages of the disease, later the sputum 
becomes abundant, mucopurulent, or purulent, containing leuco- 
cytes, epithelial cells, elastic fibers, tubercle bacilli, and various 
associated bacteria. Small yellowish caseous masses are fre- 
quently found in the sputum, which are most intimately associ- 
ated with the tubercle bacillus. Occasionally the sputum is 
blood-tinged or contains free blood. Hemoptysis is a valuable 
sign of the disease. 

Palpation. — In incipient phthisis palpation of the apices is apt 
to reveal the presence of deficient expansion at one apex. In apical 
consolidation palpation of the infraclavicular region yields in- 
creased vocal fremitus. In view of the fact that vocal fremitus is 
normally more intense over the right apex than it is over the left, 
an equalization of the fremitus upon the two sides points to con- 
solidation of the left apex. 

In advanced phthisis, over densely infiltrated or consolidated 
areas of the lung vocal fremitus is exaggerated. The fremitus 
exhibits the acme of exaggeration over a superficial cavity with 
patent bronchial communication. Extensive pleural thickening, 
pleural exudate, or pleural effusion effectually masks or abolishes 
the vocal fremitus. With less constancy it is possible to elicit 
friction fremitus or rhonchal fremitus upon palpation of the thorax 
over an area of consolidation. 

Early in the course of the disease the pulse is moderately in- 
creased in rate, but not out of proportion to the fever, and its 
volume is maintained. In the further evolution of the disease the 
frequency is increased with diminution in the volume combined 
with arrhythmia of the pulse. 

Fercussion. — In incipient phthisis percussion of the apices in 
the supraclavicular, infraclavicular, suprascapular, and upper 



262 PHYSICAL DIAGNOSIS 

interscapular regions is apt to yield moderate impairment of reso- 
nance over one apex. While the percussion note as elicited by 
percussion over the right apex is normally of slightly higher pitch 
than the note which is elicited over the opposite apex, the difference 
is not sufficiently marked to become a serious source of error in 
a carefully conducted examination. Dullness of one apex may be 
elicited by immediate percussion by tapping the clavicle upon either 
side and noting any discrepancy in the quality and pitch of the 
notes which are elicited. In incipient phthisis occasionally sharp 
pain is elicited by percussion of the infraclavicular region, con- 
stituting Roussel 's sign of the disease. 

In advanced phthisis percussion of the thorax yields dullness 
over areas of consolidation and flatness in the presence of coexisting 
pleural effusion. A tympanitic note elicited during this stage of 
the disease is indicative in the vast majority of instances of tuber- 
culous or bronchiectatic cavity formation. A similar tympanitic 
note may, however, be produced by an area of superficial con- 
solidation which is immediately superimposed upon a large bron- 
chus. In the presence of cavitation, it is usually possible to elicit 
the cracked-pot sound by percussion ; and with less constancy the 
signs of Wintrich, Friedreich and Gerhardt may be elicited. Signs 
of cavity in the upper lobes point strongly to a tuberculous rather 
than to a bronchiectatic origin. An apical cavity which contains 
fluid yields dullness rather than tympany upon percussion. How- 
ever, it is frequently possible by repeated percussion blows de- 
livered over such a cavity to excite a paroxysm of cough, which 
effectually expels the contents of the cavity, whereupon percus- 
sion over the cavity yields cavernous tympany (Erni's sign). 

Upon percussion of the pectoral muscles in advanced phthisis a 
sudden, localized contraction of the muscle ensues (myoidema) 
which merely indicates that atrophy is progressing rapidly and is 
in no wise pathognomonic of chronic ulcerative phthisis. 

Auscultation. — Auscultation of the lungs usually affords the 
earliest evidence of the presence of chronic ulcerative phthisis. In 
incipient phthisis the respiratory murmur is partially suppressed ; 
and in certain cases it is possible to detect jerky or cog-wheel 
breathing, in which during inspiration the murmur is interrupted 
at several points, producing a sound similar to that of a sobbing 
child. With less constancy in the early period of the disease a 
pleural friction sound is audible. 

One of the earliest signs of the disease is the crepitant rale. As 
the consolidation increases, the breath sounds become broncho- 



DISEASES OF THE LUNGS 263 

vesicular and finally bronchial, associated with increase of vocal 
resonance, bronchophony, or pectoriloquy. A pulmonary cavity 
is indicated by the development of whispering pectoriloquy, with 
cavernous or amphoric breathing. On the contrary, a cavity which 
is filled with fluid or whose bronchial outlet is occluded gives forth 
no physical signs upon auscultation. But when such a cavity is 
only partially filled, there are frequently audible moist and gurg- 
ling rales upon change of posture, and less frequently the metallic 
tinkle or the succussion sound, if the cavity be of sufficient size 
and peripherally located. 

The presence of the lung-fistula sound indicates that pneumo- 
thorax has occurred, as a result of rupture of a subpleural cavity. 
The mucous click, a sharp clicking subcrepitant rale, is audible in 
certain cases of advanced phthisis, and is thought to indicate rapid 
softening. 

Diagnosis. — Chronic ulcerative phthisis in its evolution and 
course produces a multiplicity of physical signs; and in the diag- 
nosis of the disease no sign, however slight it may appear in 
itself, should be overlooked. The greatest difficulty in diagnosis 
arises in the incipient cases; but it is in just these cases, in which 
the possibility of ultimate recovery from the disease has not 
absolutely passed, that it is most important to diagnose the 
disease. 

Signs and symptoms which point surely to chronic ulcerative 
phthisis comprise emaciation, anemia, often marked in degree, 
fever, a symptom which is invariably present, night sweats, 
cough, pain in the thorax, dyspnea on exertion, and hemoptysis. 
Add to this the characteristically deformed thorax, the hectic 
flush of the established case, and the diagnosis is yet more prob- 
able. A history of the disease in the antecedents, or the discovery 
of a tuberculous focus somewhere in the body is of service in 
arriving at a diagnosis. The diagnosis is confirmed by the de- 
tection of the tubercle bacillus in the sputum. In the young 
subject the tuberculin reaction is of value. 

In interpreting the physical signs, especial weight should be 
laid upon areas of deficient expansion, dullness at the apices, 
harsh and prolonged expiration, and rales which persist and are 
repeatedly audible in the same area. 

Differential Diagnosis. — Malaria may be simulated by the fever 
of chronic ulcerative phthisis, with chills and sweats ; but the blood 
is negative for the malarial plasmodium, and the sputum is apt to 



264 PHYSICAL DIAGNOSIS 

" « 

show the tubercle bacillus. Moreover, there is frequently a history 
of tuberculosis in one of the antecedents. 

Consolidations of the lung due to lobar or lobular pneumonia 
are differentiated from that of tuberculosis by the different clin- 
ical courses of these diseases and by the absence of the tubercle 
bacillus from the sputum. 

Broncliiectasis, pulmonary ahscess, and pulmonary gangrene^ 
while productive of physical signs suggestive of phthisis, are dif- 
ferentiated by the distribution of the signs and the absence of tu- 
bercle bacilli from the sputum. 

FIBROID PHTHISIS 

Clinical Patholog-y. — Fibroid phthisis is a form of chronic pul- 
monary tuberculosis, in the evolution of which the predominant 
feature is the formation of an excessive amount of fibrous con- 
nective tissue. In the incidence of the disease the tuberculous 
infection of the lung may- be the primary affection, and through 
the process of reparative sclerosis the disease may assume the 
fibroid type. On the contrary, the tuberculous infection may be 
engrafted upon a lung which was previously fibrosed, either as a 
result of pneumonokoniosis or chronic interstitial pneumonia fol- 
lowing an unresolved lobar pneumonia which has healed by scle- 
rosis, or a pleurogenous interstitial pneumonia. 

In the cases which are primarily tuberculous, the disease has 
its inception in an apex of one or both lungs; and, as in other 
forms of the disease, it progresses downward, involving the lower 
lobes in regular progression. In this class of cases one apex may 
be sclerosed, or the entire lung may be sclerotic and shrunken, 
showing cavities and bronchial dilatations, which may be empty 
or which may be filled with caseous material. In many instances 
the only way of determining whether a pulmonary fibrosis is tu- 
berculous or nontuberculous is by the presence or absence of the 
tubercle bacillus in the sputum during the life of the patient. 

The distribution of the fibrosis is largely influenced by the man- 
ner of production of the disease. In cases which arise from in- 
halation through the respiratory passages, the formation of con- 
nective tissue assumes the character of a peribronchial fibrosis, 
and is most pronounced around the bronchi and bronchioles ; 
whereas in the cases which develop as a sequela of tuberculous 
pleurisy the peripheral portions of the lung are most extensively 



DISEASES OF THE LUNGS 265 

involved and bands of fibrous connective tissue pass from the 
pleura into the deeper portions of the lung'. 

Whatever the mode of production of the disease, the ultimate 
result is a marked diminution in the size of the lung which is 
shrunken, pigmented, and occupies a very small area of the upper 
portion of the pleural cavity near the vertebral column. 

Physical Signs. — Inspection. — The physical findings in fibroid 
phthisis are almost identical with those of chronic interstitial 
pneumonia. The side of the thorax corresponding to the fibrosed 
lung is shrunken, presenting local retractions, with drooping 
shoulder, and a minimal degree of expansion in the advanced case 
of the disease. Scoliosis is frequently present with the thoracic 
deformity, with the concavity directed toward the side of the dis- 
ease. Likewise, the cardiac impulse is displaced toward the side 
of the cirrhotic lung. In left-sided disease there is frequently a 
wide impulse in the third and fourth interspaces ; while in disease 
of the right lung the impulse is frequently invisible, as it is dis- 
placed toward the right to such degree as to lie behind the 
sternum. 

The intercostal spaces are narrowed, and the ribs occasionally 
overlap upon the side of the diseased lung. The depressions of 
the supraclavicular and infraclavicular regions are abnormally 
deep, and the clavicles are unduly prominent. The sound side of 
the thorax presents vicarious expansion as a result of compensatory 
emphysema of the sound lung. 

Palpation. — In incipient cases palpation is serviceable in detect- 
ing slight degrees of deficient expansion which have escaped 
detection during inspection of the thorax. Vocal fremitus varies 
in intensity with the condition of the lung and the pleura. Pal- 
pation of the thorax overlying a cirrhotic lung which is imme- 
diately subjacent to the chest wall and palpation over pulmonary 
cavities yield exaggeration of vocal fremitus; whereas in the 
presence of excessive pleural thickening, and when the lung is 
shrunken and is not in contact with the thoracic parieties, vocal 
fremitus is diminished in intensity or is abolished. Similarly, 
when the fibrosis is centrally situated and is covered by normal 
pulmonary tissue, vocal fremitus is unaltered or is actually dimin- 
ished. Upon palpation of the thorax over the sound lung, in 
unilateral disease, vocal fremitus is diminished as a result of rare- 
faction of the lung due to compensatory emphysema. 

Percussion. — Percussion of the apex upon the diseased side 
usually elicits impairment of resonance owing to retraction of 



266 PHYSICAL DIAGNOSIS 

the pulmonary apex. Cavitation in the upper lobe of the lung 
is indicated by hyperresonance or tympany in the infraclavicular 
region. In cases with excessive pleural thickening the percussion 
note is impaired and there is a marked sense of resistance as ap- 
preciated by the pleximeter finger. Tympany over the lower lobe 
of the lung is indicative of cavitation which is commonly bron- 
chiectatic in origin. Percussion of the sound lung in unilateral 
disease yields hyperresonance. 

Auscultation. — The respiration over the upper lobe of the lung 
in the infraclavicular region is commonly bronchovesicular or 
frankly bronchial ; and in the presence of cavitation in this region 
is amphoric or cavernous. At the bases there is frequently dis- 
tinct bronchial breathing, unless the disease be so advanced that 
the lung is retracted into the upper portion of the pleural cavity, 
in which event the respiratory murmur is distant or entirely in- 
audible. Rales of chronic bronchitis are quite constantly present 
over the diseased lung. The pulmonic second sound is apt to 
show accentuation. 

Diagnosis." — Deformity ' of the thorax, the wide area of the 
cardiac impulse in left-sided disease and absence of the impulse 
very frequently in right-sided disease, the bronchial or amphoric 
breath sounds over an apex of the lung, associated with dullness 
or tympany as the case maj^ prove, indicate fibrosis of the lung 
with cavity formation. Whether or not this is tuberculous in 
origin is to be determined by the examination of the sputum for 
the tubercle bacillus. But in fibroid phthisis, in contradistinc- 
tion from the fibrosis of chronic interstitial pneumonia, the dis- 
ease is apt to be bilateral, whereas in the case of fibrosis from 
chronic interstitial pneumonia it is apt to be unilateral. It fol- 
lows that careful examination of both lungs should be practiced 
for the purpose of detecting signs of disease in an apparently 
normal lung. 

PULMONARY SYPHILIS 

Clinical Pathology. — Syphilis attacks the lung in two forms ; 
namely, as congenital syphilis, and as acquired syphilis of the lung. 

Congenital syphilis of the lung was first described by Virchow as 
''pneumonia alba." The lung in congenital syphilis is enlarged, 
showing on its external surface indentations corresponding with the 
ribs with which it is in contact. The lung is white or slightly tinged 
with yellow ; it is firm ; and upon section the cut surface resembles 



DISEASES OF THE LUNGS 



267 



macroscopically a section of pancreatic tissue, a condition to which 
Lorain and Robin applied the term ' ' pancreatization. ' ' 

Microscopically the interalveolar septa show an overgrowth of 
fibrous connective tissue, leading to thickening of the alveolar walls, 
the alveolar spaces being smaller than normal and densely packed 
with desquamated epithelial cells, cellular detritus, and fat. Hoff- 
man called attention to a thickening of the vascular walls in the 
interalveolar septa, analogous to that which occurs in syphilitic 
fetal tissue elsewhere, the vessels often presenting, as well, evi- 
dences of hyaline degeneration. 

The lesions of acquired syphilis of the lung may assume three 
types; namely, gummata, interstitial sclerosis analogous to chronic 




Fig. 113. — Pneumonia alba of newborn. (From McFarland.) 

interstitial pneumonia from other causes, and syphilitic broncho- 
pneumonia. 

The gummata are situated deeply near the root of the lung, vary- 
ing in size from a hazelnut to a hen's egg or larger. They are prone 
to soften and to break into a bronchus or to undergo sclerosis and 
by traction lead to bronchiectatic dilatations. Gummata are the 
rarest of syphilitic lesions of the lungs. Wagner and Henop de- 
scribed gummata in both the upper and lower lobes of the lung, 
situated principally toward the root, usually containing in their 
center a dilated bronchus with chronically inflamed mucous mem- 
brane. The lung intervening between the gummata was partially 
crepitant, while the apices and anterior borders of the lungs were 
in a state of compensatory emphysema. 

The interstitial sclerosis attending acquired syphilis of the lung 



268 PHYSICAL DIAGNOSIS 

■ • 

has its inception near the root of the lung, and extends thence in 
various directions between the lobules of the lung. The patches of 
insular sclerosis often extend in all directions from gummata situ- 
ated near the pulmonary root, dividing the lung into a number of 
artificial subdivisions. Traction diverticula are formed, which lead 
to bronchiectases. 

The bronchopneumonia of syphilis does not differ essentially 
from bronchopneumonia of other causes, Pavloff describing a 
bilateral, syphilitic bronchopneumonia with patches of consolida- 
tion interspersed between areas of normal tissue in both lungs. 
The alveoli are filled with desquamated epithelial cells, with a vari- 
able number of erythrocytes and leucocytes, the pneumonic patches 
being dull slate-colored upon section. 

Physical Signs. — Congenital syphilis of the lung must in certain 
instances be differentiated from atelectasis, which it closely simu- 
lates; but there are usually sufficient evidences of congenital 
syphilis upon the exterior of the body to render the diagnosis 
clear. 

The physical signs of acquired syphilis are not characteristic, 
the clinical picture being often that of chronic interstitial pneu- 
monia, from other causes, chronic ulcerative phthisis, or ordinary 
bronchopneumonia. However, there are certain localizations of 
the principal signs emanating from pulmonary syphilis which 
are of considerable aid in diagnosis. Thus, the lesions are usually 
situated near the root of the lung, gummata and sclerosis in this 
situation giving rise to dullness upon percussion and bronchial 
breath sounds upon auscultation along the lateral sternal bor- 
ders, over the roots of the lungs, which signs decrease in intensity 
as the examiner progresses outward, iipward, and downward 
from this area. Grandidier lays great emphasis upon the locali- 
zation of the physical signs in these regions of the thorax, while 
Pankritius points out the importance of dullness in the inter- 
scapular regions at the same level. 

The disease is productive of chronic cough, which is not in- 
frequently attended by hemoptysis and fever, simulating rather 
closely the picture of chronic ulcerative phthisis; but there can 
often be found evidences of syphilis in other regions of the body, 
and the specific tests for syphilis are available. 

PNEUMONOKONIOSIS 

Clinical Pathology. — Pneumonokoniosis is a chronic induration 
of the lungs due to the inhalation of various dusts and mineral 



DISEASES OF THE LUNGS 



269 



particles. Depending upon the nature of the exciting cause, the 
disease is subdivided into several different types : siderosis, from 
the inhalation of iron filings; cJialicosis, from the inhalation of 
stone particles; and antJiracosis, from the inhalation of coal dust. 
Similar pulmonary changes ensue upon the continued inhalation of 




Fig. 114. — Anthracosis. (From Delafield and Prudden.) 



270 PHYSICAL DIAGNOSIS 

" * 

the fibers of wool, flax, cotton, tobacco, or particles of glass, bone, 
or horn, in the course of an occupation. 

Anthracosis, or "ccal miner's disease," arises as the result of the 
prolonged inhalation of fine particles of coal. The minute amounts 
of this dust which are usually inhaled by persons who do not pursue 
an occupation which habitually brings them into contact with coal 
dust are absorbed by the leucocytes which are present upon the 
surfaces of the respiratory passages; and they are carried upward 
by the action of the ciliated epithelium of the respiratory tract, 
and are expectorated. When, however, the dust is inhaled in larger 
amount, some of the coal particles penetrate the bronchial mucous 
membrane and find lodgment in the subjacent connective tissue 
layer, or enter the lymph stream and are conveyed to the smaller 
lymphatic glands around the blood vessels, the bronchi, the pleura, 
or in the mediastinum. The lungs of all dwellers in cities are 
moderately pigmented from the inhalation of coal dust and soot, 
while the lungs of persons who have lived all their days in the open 
country, remote from large manufacturing industries, are fre- 
quently pink in color and free from this pigmentation. 

When soot or coal dust is inhaled in excessive quantities, as in 
the case of the coal miner, a portion of it penetrates to the ulti- 
mate ramifications of the bronchioles and to the pulmonary alveoli. 
In the lungs which are the seat of this extreme grade of anthracosis 
the organs are distinctly black. The irritation of the fine grains 
of dust in the interstices of the pulmonary tissues excites the pro- 
liferation of fibrous connective tissue, resulting in fibrosis in insular 
feci. Upon section these fibrosed areas are hard to the touch and 
they exude a black fluid. Diffuse induration of an entire lung, or of 
the greater portion of a lung, is com,monly encountered at autopsy. 

The bronchial and mediastinal lymphatic glands share in the 
general induration, and they are frequently the seat of periadenitis 
by virtue of which they adhere to the adjacent large vessels, and 
by rupture into the same they distribute the pigmentation to vari- 
ous organs of the body, as the liver, spleen, kidneys, and mesenteric 
lymphatic glands. 

Bronchial perilymphadenitis may lead to the formation of adhe- 
sions between the glands and the pericardium, producing a chronic 
mediastinopericarditis. Adhesions are apt to form between these 
glands and the esophagus, and lead to the formation of esophageal 
diverticulum. Similarly adhesions are prone to form between the 
mesenteric glands and the aorta, with subsequent erosion of that 
vessel with fatal hemorrhage. Adhesive bands may also constrict 



DISEASES OF THE LUNGS 271 

the trachea or adjacent blood vessels, producing tracheal stenosis 
with stridulous respiration, or vascular constriction with the pro- 
duction of murmurs. Adhesions may produce aspiration pneu- 
monia when a gland erodes a bronchus and discharges its contents 
by that avenue. Moreover, the chronically inflamed glands may 
produce vagus or recurrent laryngeal nerve paralysis by pressure 
upon these nerves. 

Chalicosis, due to the inhalation of the fine dust of alumina, 
quartz, or sandstone, is known as "stone-cutter's phthisis," mill- 
stone maker's phthisis," "grinders rot," or "potter's asthma." 
Chalicosis produces a greater degree of induration of the lung than 
does any other form of pneumonokoniosis. 

Siderosis is a fibrosis of the lung due to the inhalation of iron 
filings or iron dust. The changes in the lungs and the mediastinal 
and bronchial glands are similar to those which accompany anthra- 
cosis; but the induration attains a greater degree than it does in 
anthracosis. 

The areas of insular sclerosis which are formed throughout the 
lungs, in certain cases undergo softening and form pulmonary 
cavities. In other instances the softening is due to subsequent in- 
fection with the tubercle bacillus; although, as a rule, the pneu- 
monokoniotic lung does not appear to prove a fertile field for the 
ravages of the tubercle bacillus. As a result of the chronic inflam- 
mation which is induced by the continual aspiration of the irritant 
dusts, the bronchial tubes show a chronic bronchitis, which is fol- 
lowed in many cases by emphysema, while the lung slowly under- 
goes a slow, insular sclerosis. 

Physical Signs. — The physical signs of pneumonokoniosis are 
modified and influenced by the coincident chronic bronchitis, 
emphysema, or interstitial sclerosis, with occasional signs of 
excavation of the lung engrafted upon these signs. Signs of 
cavity suggest chronic ulcerative phthisis or bronchiectasis, and 
it should be borne in mind that both diseases are possible compli- 
cations of pneumonokoniosis. In a typical case of pneumono- 
koniosis the physical signs are evolved with a fair degree of 
regularity. The earliest signs to become manifest are those of a 
chronic bronchitis ; then there appears the picture of a gradually 
developing hypertrophic emphysema ; and finally signs of chronic 
interstitial pneumonia become evident, with or without signs of 
bronchiectasis or cavitation. 

The sputum in these cases is frequently of assistance in estab- 
lishing the diagnosis. In anthracosis it is black from the content 



272 PHYSICAL DIAGNOSIS 

" * 

of coal dust; in siclerosis it is reddish or brown; while in chalico- 
sis the shining particles of stone dust can be seen microscopically. 
Diagnosis. — The diagnosis is to be founded upon a history of an 
occupation which requires the long-continued inhalation of dusts, 
and upon physical signs of chronic bronchitis, emphysema, and 
insular sclerosis of the lung, with or without evidences of cavity 
formation, and upon the characteristic sputum. Late in the 
course of the disease, the sputum in a suspected case may show 
the tubercle bacillus from subsequent tuberculous infection. 

ATELECTASIS 

Clinical Pathology. — Imperfect expansion of the lung or partial 
collapse of a lung which has become fully expanded may be con- 
genital or acquired. In the congenital form of atelectasis the 
lung has never attained its proper degree of expansion; while in 
the acquired form, which is a disease of later life, there occurs 
from various causes a partial collapse of the lung. 

Congenital atelectasis is a disease of the newly born, developing 
usually as a result of insufficient inflation of the lung due to the 
aspiration of meconium or mucus during parturition, or from ab- 
normal weakness of the respiratory muscles subsequent to birth. 
In atelectatic children who survive, the anterior borders and the 
apices of the lungs are partially inflated, while the central and 
lower portions of the lungs are brownish red, vascular, and fail to 
crepitate upon manipulation. 

As the child gains strength the anterior and upper portions of the 
lungs become emphysematous from compensatory emphysema, 
while the deeper portions are very tardy in attaining their proper 
degree of expansion. Congenital atelectasis is a bilateral disease, 
affecting both lungs, and usually to a similar degree. It is probable 
that the central portions of the lungs of atelectatic children never 
attain to full inflation, as the tendency is rather for secondary 
changes to occur, which lead to sclerosis and contraction of the 
deeper portion of the lung near the pulmonary root. 

Acquired atelectasis is frequently the result of compression of 
the lung by a pleural effusion, a tumor, aneurysm, or deformity of 
the thoracic wall. The most fruitful source of the disease, however, 
is bronchial obstruction from foreign bodies, or external pressure 
from a pulmonary tumor or aortic aneurysm. Similarly, in the 
course of capillary bronchitis or bronchopneumonia the terminal 
bronchioles are obstructed by inflammatory exudate, leading to 



DISEASES OF THE LUNGS 273 

circumscribed areas of atelectasis. Conditions of great debility, 
the result of malnutrition or lying long in the recumbent posture 
with an exhausting disease, occasionally induce areas of circum- 
scribed atelectasis. 

The atelectatic area of the lung is darker than the adjacent tis- 
sues, is depressed below the surface of adjacent areas of the lung, 
and is usually distributed in a number of areas corresponding to 
lobules of the lung. Upon section the areas are usually dry, but 
they may be moist from the presence of chronic passive congestion. 

Physical Signs. — The physical signs of atelectasis are influenced 
and modified by the primary manifestations of the disease or 
condition which has been the occasion of the atelectatic state of 
the pulmonary tissues. The signs also vary in intensity with the 
volume of lung involved in the atelectasis and the condition of 
the undiseased portion of the bronchopulmonary system. It is 
obvious that the physical signs arising from collapse of an entire 
lobe or an entire lung will differ markedly in distribution and 
degree from those which are referable to a few scattered areas 
of pulmonary collapse. 

Inspection. — Extensive atelectasis, involving a considerable area 
of a lung, gives rise to dyspnea and occasionally to cyanosis, with 
inspiratory retraction of the lower intercostal spaces and the epi- 
gastrium. In congenital atelectasis the child suffers with repeated 
suffocative attacks during which immediate dissolution seems to be 
imminent. The expansion of the thorax is materially diminished 
in extensive atelectasis. 

Palpation. — ^Vocal fremitus over the area of disease may be 
diminished, absent, or exaggerated, depending upon the state of 
the pulmonary parenchyma. Collapsed, toneless pulmonary tissue 
fails to conduct the vocal vibrations with the normal intensity ; and 
if a main bronchus is completely obstructed, there is absence of 
vocal fremitus over the distribution of the bronchus. However, 
when secondary changes have been established in a case of atelecta- 
sis with partial bronchostenosis, the fremitus is transmitted by the 
consolidated or sclerotic tissues with undue intensity to the thoracic 
wall. Pleural friction fremitus is occasionally demonstrable, due to 
involvement of the pleura over the atelectatic area. 

Percussion. — The dullness which would be produced by small 
patches of atelectasis is effectually masked by the hyperresonance 
of the adjacent emphysematous areas. In order to afford dullness 
upon percussion an area of atelectasis must be large and situated 
in the peripheral portion of the lung. A patch which directly over- 



274 PHYSICAL DIAGNOSIS 

■ * 

lies a large bronchus yields the tympany of the bronchus upon 
forcible percussion. Deeply seated areas of atelectasis fail to yield 
dullness, owing to the intervention of the normal crepitant tissues 
between the area of disease and the chest wall. 

Auscultation. — The vesicular murmur is feeble or abolished over 
an area of atelectasis, unless the area of collapse overlies a large 
bronchus, in which event the murmur is bronchovesicular or 
frankly bronchial. In the presence of nonextensive areas of col- 
lapse the only auscultatory sign may be the presence of a few 
crepitant rales upon full inspiration. This holds true of the cases 
of atelectasis which develop in the dependent portions of the lungs 
in patients who have been long in the recumbent posture with 
exhaustive disease. In cases of extensive atelectasis the second 
sound of the heart is accentuated at the pulmonary area. 

Diagnosis. — The diagnosis of pulmonary atelectasis is fre- 
quently for a time difficult or impossible. The finding of res- 
piratory embarrassment and the location of some adequate 
causative lesion such as bronchial obstruction or pulmonary 
compression is suggestive. The physical signs are seldom definite 
and distinctive, as small areas of collapse have their physical 
signs effectually masked by the emphysematous state of the 
surrounding lung. Moreover, as a larger area of collapse is apt 
to overlie a large bronchus and to have its tympanitic note en- 
grafted upon the dullness of the atelectasis, a pulmonary cavity 
is apt to be suspected w^iere none exists. The fact that the physi- 
cal signs have a tendency to improve and to regress with changes 
of posture and with deep inflation of the lungs is suggestive of 
atelectasis. 

HYPERTROPHIC EMPHYSEMA 

Clinical Pathology. — In hypertrophic emphysema, idiopathic, 
or substantive emphysema, or the large-lunged emphysema of 
Jenner, the lungs are enlarged, the air cells are greatly distended 
with air, and the interalveolar septa are thinned and atrophic. 
The disease is also known by the names of chronic and diffuse 
emphysema. 

The disease is usually encountered in persons who suffer with 
chronic bronchitis or whose occupations require forcible expira- 
tion with the glottis closed, as in the case of glass-blowers and 
players upon wind instruments. It is probable that impaired 
nutrition of the alveolar walls, with the result that the elastic 



DISEASES OF THE LUNGS 



275 



tissue is unable to contract and adequately expel the air from the 
infundibula plays a part in the production of the disease. 
Freund's theory of the mechanism of production of hypertrophic 
emphysema assumes that it is primarily a disease of the costal 
cartilages; that there is a chronic hyperplasia of these cartilages, 
which by ossifying prematurely cause the thoracic wall to lose 
its elasticity, the emphysema of the lungs developing secondarily 
as a result of lack of proper support to the lungs. 

Hypertrophic emphysema is a bilateral disease, and involves 
both lungs to a similar degree. The distention of the lungs is 




Fig. 115. — Pulmonary capillaries. The walls of the alveoli are thickly studded with 
capillaries; any marked alteration of alveolar air tension will therefore have a profound 
effect upon the circulation. (Brown, after Bohm, Davidoff, and Huber.) 

general in all directions, but it attains its maximum degree in the 
anterior pulmonary borders, which, overlapping the heart, give 
rise to a diminution of the area of that organ which is in contact 
wdth the anterior chest and causes a consequent diminution in the 
area of cardiac dullness. The lungs are enlarged; they are pale; 
they are light and feathery to the touch ; and they do not collapse 
readily when the thorax is opened at autopsy. 

Microscopically the alveoli are observed to be abnormally 



276 PHYSICAL DIAGNOSIS 

large, and it is observed that in many instances the interalveolar 
septa are atrophic and have ruptured, leading to the production 
of larger cavities by the coalescence of several alveoli. With the 
destruction of the alveolar septa, the capillaries which they sup- 
ported are destroyed, and the quantity of blood which is exposed 
to the air in the infundibula is commensurately diminished, re- 
sulting in deficient aeration of the blood, with consequent dysp- 
nea and occasionally cyanosis upon moderate exertion. 

The pleura covering the lung loses its pigmentation in patches, 
a condition which was termed by Virchow ''albinism of the lung." 
The bronchi and bronchioles show signs of chronic bronchitis, 
and bronchiectatic dilatations are common. 

The right heart gradually hypertrophies, as a result of the in- 
creased burden which is thrown upon it, and the tricuspid ring 
is usually enlarged so that the valve segments often fail to close 
the orifice completely. 

Rupture of the atrophic walls of the infundibula subjacent to 
the pleura may result in the production of pneumothorax. 

Physical Signs. — Inspection. — Hypertrophic emphysema pro- 
duces a definite alteration in the size and shape of the thorax, the 
barrel-chest of this disease. In this type of thorax, the antero- 
posterior diameter is increased to such a degree that it equals or 
exceeds the transverse diameter. The expansion of the chest is 
minimal, the thorax rising and falling vertically en masse. The 
expiratory movement is of longer duration than is the inspiratory 
effort. 

The cardiac impulse is often invisible, and there is frequently 
visible epigastric pulsation, while pulsation of the jugular veins 
is common. In the late period of the disease, when cardiac failure 
is imminent, the patient is dyspneic, and frequently cyanotic. 
Not infrequently there is a delicate tracery of distended veins over 
the lower portion of the thorax, produced by intrathoracic obstruc- 
tion to the venous return. 

The facies of hypertrophic emphysema is fairly characteristic of 
the disease. The eyes are slightly prominent ; the nose is somewhat 
thickened and cyanotic ; while the head is thrown slightly backward 
in the effort to bring the accessory muscles of respiration into play. 
The neck is short and thick with prominent sternomastoids and 
trapezii. 

Litten's diaphragmatic shadow is abolished in the established 
case of hypertrophic emphysema; the subject presents persistent 



DISEASES OF THE LUNGS 277 

chronic cough; and the terminal phalanges of the fingers are fre- 
quently clubbed. 

Palpation. — As a consequence of the excessive aerial content of 
the lungs, vocal fremitus is diminished in intensity over both sides 
of the thorax. However, in cases with marked chronic bronchitis, 
rhonchal fremitus is occasionally encountered. Also occasionally 
the intervention of the voluminous anterior pulmonary borders 
between the heart and the chest wall obscures the cardiac impulse. 
Frequently there is a palpable impulse in the epigastrium which 
is due to the powerfully acting right ventricle. The liver is seldom 
displaced sufficiently to render its lower border freely palpable 
below the right costal arch; but in late cases, when right heart 
failure is imminent, palpation of the liver frequently reveals the 
systolic pulsation of tricuspid regurgitation. The spleen is rarely 
displaced in hypertrophic emphysema. In late cases palpation of 
the abdomen may reveal the presence of moderate ascites. 

Palpation reveals the deficient expansion of the thorax ; and upon 
finger-tip palpation the intercostal spaces are hard and unyielding. 
Percussion. — Percussion yields a hyperresonant note over both 
lungs; and the limits of pulmonary resonance are extended in all 
directions, upward into the root of the neck, anteriorly, encroach- 
ing upon the area of cardiac dullness, and inf eriorly over the areas 
of hepatic and splenic dullness. Percussion is useful in detecting 
downward displacement of the liver, and the presence of ascites by 
eliciting dullness in the flanks with tympany in the median line of 
the abdomen. 

The respiratory excursion of the lungs, as determined by per- 
cussing the lower borders of the lungs during expiration and in- 
spiration, respectively, is greately diminished in hypertrophic 
emphysema, rarely indeed exceeding half an inch. 

Auscultation. — The respiratory sounds are distant, with pro- 
longation of the expiratory phase. The expiratory murmur is 
harsh and is not infrequently dotted with rales which are due to 
chronic bronchitis. The inspiratory murmur is always short, and 
often it is entirely inaudible during quiet breathing. Vocal reso- 
nance, like vocal fremitus, is impaired over both lungs. 

The heart sounds as a whole are diminished in intensity, owing to 
the intervention of the distended anterior borders of the lungs 
between the heart and the chest wall. Of the individual sounds, the 
pulmonary sound is accentuated, as a result of the obstacle which 
is offered to the pulmonary circulation. Late in the disease the 
murmur of tricuspid regurgitation is often audible. 



278 PHYSICAL DIAGNOSIS 

■ * 

Diagnosis. — The diagnosis of hypertrophic emphysema is fre- 
quently to be made during a casual examination. It rests upon 
the characteristic deformity of the thorax, associated with dysp- 
nea and cyanosis, persistent chronic cough, the short or absent 
inspiratory murmur, and the prolonged, harsh expiratory 
murmur. 

Differential Diagnosis. — Chronic hronchiUs, with its chronic 
cough, shortness of breath upon exertion, and slightly prolonged 
expiratory murmur, simulates hypertrophic emphysema; but this 
disease is not attended in its early stages by deformity of the 
thorax, neither does it as a rule show general extension of the limits 
of pulmonary resonance, which forms so distinctive a feature of 
hypertrophic emphysema. However, the two diseases frequently 
coexist. 

Pneumothorax, which in its incipiency may resemble hyper- 
trophic emphysema, is a unilateral affection, which develops rap- 
idly, affording a hollow and tympanitic note upon percussion, 
frequently also the succussion sound, the metallic tinkle, and the 
coin test, which serve to differentiate it from hypertrophic 
emphysema. 

ATROPHIC EMPHYSEMA 

Clinical Pathology. — Atrophic emphysema, a iDulmonary dis- 
ease in which the total bulk of the lung is decreased, is a senile 
change, a part of the general wasting of the tissues of the body 
incident to advanced age. The disease, if such it may be styled, 
is associated with persistent chronic cough, lasting over a period 
of many years, and associated with chronic shortness of breath 
upon exertion. 

In the subject of atrophic emphysema the thorax is abnormally 
small, the obliquity of the ribs is increased, and the excursion of 
the thorax during respiration is distinctly limited. 

The lung as a whole is reduced in size ; the pleura is deeply 
pigmented ; and the pulmonary parenchyma shows, evidence of 
pulmonary congestion, edema, or infarction. The bronchial tubes 
frequently present dilatations, which are surrounded by areas of 
induration. 

Microscopically there is atrophy and rupture of many of the 
interalveolar septa, leading to the formation of larger chambers 
by the coalescence of several smaller ones. The capillaries which 
the alveolar walls supported are destroyed in the areas of alveolar 



DISEASES OF THE LUNGS 279 

rupture, decreasing the quantity of blood which is exposed to the 
air in the infundibula. 

Physical Signs. — Inspection. — In the subject of atrophic emphy- 
sema the thorax is small ; the intercostal spaces are narrowed ; the 
ribs pursue a more oblique course than normally ; the supraclavicu- 
lar and infraclavicular fossae are of abnormal depth ; and the 
thoracic excursion during* respiration is slight. The dyspnea of 
atrophic emphysema, instead of being chiefly expiratory as in 
hypertrophic emphysema, is mixed, the duration of the two phases 
of the respiratory cycle being approximately equal. 

Palpation. — Upon palpation of the small thorax of the subject 
of atrophic emphysema vocal fremitus is as a rule moderately exag- 
gerated, owing to the increased density of the lungs and to the 
diminution in their air content. 

Percussion. — In atrophic emphysema the limits of pulmonary 
resonance are decreased in all directions. Even within the areas 
of resonance, as determined by percussion of the thorax, there is 
moderate impairment of the normal vesicular quality of the reso- 
nance, attributable over the apices to fibrosis and condensation of 
the pulmonary tissues, and over the bases posteriorly to edema, 
congestion, or infarction. The area of cardiac dullness is extended, 
as a result of shrinking of the lungs, exposing a large area of the 
heart to the anterior chest wall. Similarly, the upper limits of the 
areas of hepatic and splenic dullness occupy an abnormally high 
position, owing to contraction of the lungs. 

Auscultation. — The respiratory murmur over the entire thorax is 
commonly feeble ; but occasionally broncho-vesicular respiration is 
encountered. In the presence of chronic bronchitis, which often 
coexists with the emphysema, the moist rales of this condition are 
in evidence over the bases of the lungs. 

Diagnosis. — The diagnosis of atrophic emphysema is readily 
made in an elderly subject with symmetrically diminished thorax, 
with a generally ^' dried up" appearance, chronic shortness of 
breath, and chronic cough of extensive duration. 

COMPENSATORY EMPHYSEMA 

Clinical Pathology. — In compensatory emphysema certain por- 
tions of a lung, or indeed an entire lung, contain an excess of air, 
as a result of a diminution of the air space of a portion of the 
same or of the oj^posite lung. Usually of transient duration, com- 
pensatory emphysema may become permanent. In inflammation 



280 



PHYSICAL DIAGNOSIS 



of the terminal bronchioles with turgescenee of the mucous mem- 
brane, obliteration of the lumen of the tubes is produced and the 
air in the infundibula is prevented from escaping during expira- 
tion, and the tendency is toward atrophy and ultimate rupture of 
the interalveolar septa. If the obstacle to the egress of the air 
persists, bullae or air spaces of variable size are formed from the 
coalescence of several contiguous infundibula and a state of 
permanent emphysema is established. 

A diffuse compensatory emphysema, involving an entire lung, 
usually results from massive pneumonia, chronic interstitial pneu- 




Fig. 116. — Cardiac displacement as result of compensatory emphysema of the right lung 
following sclerosis of left lung. 

monia, or a large pleural effusion interfering with the expansion 
of the opposite lung during inspiration. Localized areas of com- 
pensatory emphysema occur in a lung which is the seat of 
atelectasis, the multiple patches of consolidation of broncho- 
pneumonia and phthisis, and in the presence of local fibrosis of 
the lung. 

Physical Sig^ns. — The physical signs of compensatory emphy- 
sema vary with the distribution of the emphysema and its degree, 
whether involving an entire lung or merely portions of a lung; 
and in the latter event, varying with the extent of the lung which 
is rendered emphysematous. 



DISEASES OF THE LUNGS 281 

Inspection. — Upon inspection in a case in which the entire lung 
is compensatorily emphysematous, there is unilateral bulging of 
the thorax corresponding to the side of the emphysema; and this 
bulging is accentuated by the retraction of the opposite side, which 
is diminished as a result of disease of the lung which has occasioned 
the emphysematous state of its fellow. Small areas of localized 
compensatory emphysema produce no alteration in the contour of 
the thorax. 

Palpation. — Vocal fremitus over a unilateral compensatory 
emphysema is diminished in intensity as a result of the rarefaction 
of the pulmonary tissues. Over the opposite lung the fremitus is 
of variable intensity, being influenced by the state of the lung 
which has resulted in the compensatory emphysema of its fellow. 
In the presence of consolidation the fremitus is commonly exag- 
gerated, whereas in the presence of extensive pleural effusion it 
is totally abolished over the effusion. 

Percussion. — Percussion in the case of compensatory emphysema 
of an entire lung yields a hyperresonant note over the emphysema, 
with dulling of the note over the crippled lung. Localized emphy- 
sema of limited extent produces no alteration in the normal reso- 
nance of the lung upon percussion. 

Auscultation. — Over an emphysematous lung the respiratory 
murmur is puerile, with slight prolongation of the expiratory phase. 
Over the opposite lung the murmur is influenced by the condition 
which was responsible for the unilateral compensatory emphysema, 
being bronchovesicular or frankly bronchial in the presence of 
consolidation of the lung, and being absent over the distribution of 
a large pleural effusion. 

Diagnosis. — A diagnosis of compensatory emphysema can 
rarely be made upon the physical signs alone, as these are fre- 
quently atypical. The history of the case should be elicited, with 
the discovery of some adequate cause of compensatory emphy- 
sema. Hyperresonance of one side of the thorax with puerile 
respiration and vicarious expansion, with dullness of the opposite 
side with possibly retraction of the thorax, and with deficient 
expansion speaks strongly in favor of compensatory emphysema. 

ACUTE VESICULAR EMPHYSEMA 

Clinical Pathology. — ^Acute vesicular emphysema is a condition 
in which the infundibula are acutely distended from expiratory 
efforts or fits of coughing in the presence of an obstacle to the 



282 PHYSICAL DIAGNOSIS 

free egress of air from the lungs. The disease is apt to develop 
during bronchopneumonia, bronchial asthma, tracheal and bron- 
chial stenosis, and during the extreme dyspneic attacks of cardiac 
failure. 

The distention of the lungs occurs abruptly; but the alveoli are 
merely transiently distended ; and large cavities are not produced 
by rupture of the interalveolar septa as in hypertrophic emphy- 
sema; for recovery ensues or death occurs ere this change super- 
venes. 

Physical Signs.^The physical signs of acute vesicular emphy- 
sema resemble in the main those of the hypertrophic form of the 
disease. There is general extension of the areas of pulmonary 
resonance ; the percussion note is hyperresonant or even tym- 
panitic; and upon auscultation there are sibilant rales univers- 
ally over both lungs, with prolongation of the expiratory murmur. 
However, these signs are transient, and auscultation of the heart 
reveals no accentuation of the pulmonic second sound. 

INTERSTITIAL EMPHYSEMA 

Clinical Pathology. -^In interstitial emphysema a variable quan- 
tity of air or gas is present in the interlobar or interlobular septa, 
or beneath the pleura. Air may gain access to these regions as a 
result of traumatism or as a consequence of violent expiratory 
efforts, when rupture of the lining epithelium affords ingress of 
air to the subjacent structures. It has also occurred during con- 
vulsions, during parturition, and as a sequence of straining at 
stool. It may be caused by ulceration of the bronchi, or by ab- 
scess or gangrene of the lung. Interstitial emphysema in the 
newly born has been caused during violent efforts to mechanically 
inflate the lungs, and it has resulted from spasmodic closure of 
the glottis. 

When air or gas has gained access to the stroma of the lung, it 
collects in the form of beads or bullas of variable size. In certain 
instances they are very small, while in other cases they attain to 
the size of a walnut. The beads of air are prone to make their 
way toward the root of the lung and into the mediastinum and 
thence to pass upward along the trachea and to appear beneath 
the skin of the base of the neck. Or the opposite sequence of 
events may be observed. Following tracheotomy wounds, air 
has entered the tissues and burrowed downward into the roots of 
the lungs and invaded the stroma of these organs. Not infre- 



1 



I 



DISEASES OF THE LUNGS 283 

quently the beads of air form biillge immediately subjacent to the 
13leura, and by rupture produce limited pneumothorax. 

Physical Signs. — Interstitial emphysema produces few physical 
signs, and the condition may escape detection entirely during a 
casual examination. When the air makes its way upward into 
the root of the neck and appears subcutaneously, it is apt to 
produce a protrusion, which, upon palpation with the finger-tips, 
yields a peculiar crackling crepitus. Large beads of air subjacent 
to the pleura are apt to yield a sound closely simulating the 
pleural friction sound. 

ABSCESS OF THE LUNG 

Clinical Pathology. — The cases of pulmonary abscess which 
come before the clinician may be classified as bronchogenic, pneu- 
mogenic, or extraneous in origin. 

The cases of bronchogenic origin develop as the consequence 
of the aspiration into the bronchial tubes of infectious material 
during or subsequent to operative procedures upon the buccal or 
nasopharyngeal structures, and as the result of the lodgment in 
the bronchi of aspirated foreign bodies. 

The initial alteration in the postoperative case is the estab- 
lishment of a local bronchitis at the site of implantation of the 
aspirated infectious material. Local ulceration of the bronchial 
mucous membrane ensues, and is attended by thinning and yield- 
ing of the bronchial wall, with the consequent production of 
bronchiectasis. With the further disintegration of the bronchial 
wall and by the extension into the bronchioles and infundibula of 
the septic bronchitis, a deglutition or aspiration bronchopneu- 
monia is established, which is prone to eventuate in pulmonary 
abscess. 

When an aspirated foreign body becomes arrested in a bron- 
chus, local infiammation and ulceration of the bronchial mucous 
membrane occurs at the site of lodgment, with the development, 
as demonstrated by Cohn, of bronchiectasis at this point, and not 
distal to the occlusion as was formerly believed. The progressive 
disintegration of the bronchial wall in these cases, combined with 
the implantation of pyogenic organisms, not infrequently is pro- 
ductive of pulmonary abscess. 

In the pneumogenic group of cases are comprised the cases of 
pulmonary abscess arising as a sequence of lobar pneumonia, 
bronchopneumonia complicating infiuenza or other acute infec- 



284 PHYSICAL DIAGNOSIS 

■ * 

tious diseases, pulmonary tuberculosis, syphilis, or actinomycosis 
of the lung. 

Pulmonary abscess complicating lobar pneumonia occurs in two 
forms; namely, as a widespread purulent infiltration of the lung, 
and as single or multiple circumscribed abscesses. A purulent in- 
filtration of the lung represents an extreme grade of gray hepatiza- 
tion with tardy resolution. Tuffier found that among forty-nine 
cases of pulmonary abscess treated surgically, in twenty-three lobar 
pneumonia only could be assigned as the cause ; while, in a series of 
one hundred cases, Wessler found thirty-seven cases to be dis- 
tinctly of pneumonic origin. 

Chronic ulcerative phthisis in the course of its evolution fre- 
quently results in pulmonary abscess. The tuberculous abscess is 
discrete and circumscribed, develops during the latter part of the 
course of the disease, and is associated with caseation and cavity 
formation. 

The cases of pulmonary abscess of extraneous origin comprise the 
cases of pyemic origin, and the "perforating abscesses" of Stokes. 
When an infectious embolus from an area of osteomyelitis or from 
a vegetation upon one of the cusps of a cardiac valve which is the 
seat of malignant endocarditis occludes a branch of the pulmonary 
artery, an infarct of the pulmonary tissues is apt to form and 
through secondary infection to eventuate in abscess of the lung. 
Pyemia is usually attended by the formation of multiple pulmo- 
nary abscesses of limited dimensions. They are usually situated in 
the periphery of the lung, immediately subjacent to the visceral 
pleura; and they assume primarily a conical form, with the base 
of the cone directed toward the pleura. 

Stokes designated as ''perforating abscesses" of the lung the 
numerous cases of pulmonary abscess in which collections of pus 
from extraneous sources involve the lung secondarily by contiguity 
of structure. The source of the pus in this class of cases is variable. 
It may originate in an abscess of the thoracic wall, an abscess of 
the liver, a perforating ulcer of the stomach, carcinoma of the 
esophagus, or suppuration of the mediastinal glands. 

Perforating wounds of the thorax occasionally eventuate in 
abscess of the lung. A penetrating missile may thus carry into the 
lung fragments of wearing apparel or other bacteria-laden material, 
which results in suppuration of the pulmonary parenchyma. 

In its dimensions a pulmonary abscess may be quite small or it 
may be very extensive, indeed, may involve the major part of a lobe 
of the lung. The pulmonary abscess is usually solitary; but in 



DISEASES OF THE LUNGS 285 

pyemic cases multiple abscesses of limited dimensions are commonly 
dispersed widely throughout the lungs. 

The shape of the pulmonary abscess is very irregular ; and an ab- 
scess is occasionally divided by tissue bands into two or more cham- 
bers or loculi. The internal surface of the abscess is irregular, 
presenting mural shreds and occasionally excrescences protruding 
into the cavity from a pyogenic membrane, which in turn is sup- 
ported by a more or less well-defined fibrous capsule, which in the 
latter stages of the disease becomes the point of inception of a 
variable degree of insular sclerosis of the involved lobe of the lung. 

Pulmonary abscess is usually, though not invariably, situated in 
the peripheral portion of the lung, subjacent to the visceral pleura ; 
and in the majority of cases it occupies the lower lobe of the lung. 
In the case of the postoperative abscess of bronchogenic origin, 
however, the abscess is not infrequently situated in the upper or 
middle lobe, especially in the case of children. Wessler found, 
upon analysis of the distribution of the lesions in his series, that 
among the postoperative aspiration cases the abscess was localized 
in the upper lobe in eighteen cases, in the lower lobe in nine cases, 
and in the middle lobe in one instance ; while among the nonaspira- 
tion cases the abscess was situated in the upper lobe in twenty-four 
cases, in the lower lobe in forty-four cases, and in the middle lobe 
in three of the subjects. 

The contents of a pulmonary abscess is purulent, containing 
shreds of elastic tissue, bacteria, cholesterin crystals, and necrotic 
debris. The organisms which are commonly present comprise the 
pyogenic streptococci and staphylococci, the pneumococcus, bacil- 
lus influenzae, and the bacillus of Friedlander, with the occa- 
sional association of the bacillus pyocyaneus, bacillus coli com- 
munis, or the bacillus tuberculosis. 

Spontaneous evacuation of a pulmonary abscess is apt to occur by 
rupture into an adjacent bronchus, in which event the purulent 
contents of the abscess cavity is partially expectorated, the shreds 
of elastic tissue in the sputum aiding materially in the diagnosis ; 
or, if the abscess is situated immediately subjacent to the pleura, 
this membrane may be penetrated, permitting the abscess to dis- 
charge into the pleural cavity with the consequent induction of 
pyo-pneumothorax. 

When an intact pulmonary abscess occupies the peripheral por- 
tion of the lung, closely subjacent to the visceral pleura, pleuritis is 
a constant accompaniment of the disease. The surface of the 
inflamed pleura is early clothed with fibrinous or fibrinopurulent 



286 PHYSICAL DIAGNOSIS 

■ * 

exudate, occasionally with the subsequent supervention of frank 
empyema. 

Bronchiectasis and pulmonary abscess are very frequently 
concomitant diseases. The existence of uncomplicated bronchi- 
ectasis lends a strong predisposition to the development of pul- 
monary abscess; while pulmonary abscess of bronchogenic origin 
induces a variable degree of bronchiectasis during its evolution. 

Postpneumonic pulmonary abscess, whether it asumes the form 
of purulent infiltration or of multiple circumscribed abscess 
cavities, produces chronic induration of the lung with diminution 
in its total bulk, marked destruction of capillary circulation, and 
multiple bronchiectases. 

Septic thrombosis of the cerebral vessels, with the induction 
of abscess of the brain, has proved a fatal complication in a con- 
siderable number of cases of pulmonary abscess. 

Physical Signs. — The physical manifestations of pulmonary 
abscess vary with the character and with the distribution of the 
lesion. Multiple small abscesses, distributed widely throughout 
the lung, and likewise a very diffuse purulent infiltration, yield 
no distinctive physical signs by which alone the condition could 
surel}^ be detected. Similarly, a solitary circumscribed abscess, 
which is situated in the depths of the lung and which is separated 
from the thoracic wall by a tolerably thick bed of crepitant pul- 
monary tissue, successfully eludes detection during a physical 
examination. It is in the cases in which the abscess is situated in 
the periphery of the lung, or when it is superimposed upon one 
of the larger bronchial tubes that a diagnosis is most readily 
achieved by the methods of physical examination. 

Inspection. — The subject of pulmonary abscess generally pre- 
sents an appearance of septic intoxication, with pallor of the skin 
and mucous membranes, which is not infrequently associated with 
a variable degree of cyanosis of the lips, ears, and finger-tips. If 
the abscess is at all extensive, there is acceleration of the respira- 
tion, which is shallow, and there is visible impairment of expansion 
of the side of the thorax corresponding to the disease of the lung. 

The decubitus of the patient will vary with the site of the dis- 
ease. When the abscess is situated in the lower lobe, the patient 
assumes the upright posture in order to maintain the sensitive 
mucous membrane of the communicating bronchial tubes free from 
the purulent contents of the abscess cavity. When, on the con- 
trar}', a solitary abscess involves the upper lobe, the subject is prone 



DISEASES OF THE LUNGS 287 

for similar reasons, to assume the recumbent or semirecumbent 
posture in bed. 

When contact of the contents of the cavity with the bronchial 
mucous membrane occasions a paroxysm of cough, or when a closed 
abscess cavity ruptures into a bronchus, copious expectoration of 
fairly characteristic sputum ensues. The sputum occasionally pos- 
sesses a somewhat sweetish odor, though the rule is rather for foul 
expectoration, which is raised in mouthfuls; but the sputum of 
pulmonary abscess never attains the excessive foulness of the ex- 
pectoration attending pulmonary gangrene. Frequently the 
sputum contains shreds of elastic tissue ; and, in the cases of exten- 
sive duration, crystals of cholesterin may be found. 

Clubbing of the fingers is not uncommon in abscess of the lung, 
and in this acute disease these changes become manifest much 
earlier in the course of the disease than in phthisis. 

Upon fluoroscopic examination, pulmonary abscess yields in the 
vast majority of cases a very definite shadow, which is of service in 
accurately localizing the disease ; but in any equivocal case the 
examiner should be guided by the physical findings rather than by 
the radiogram. 

Palpation. — When pulmonary abscess is situated in the periph- 
eral portion of the lung, closely subjacent to the visceral pleura, 
friction fremitus which is produced by a coincident pleuritis may 
occasionally be detected upon palpation of the thorax. Finger-tip 
palpation of the intercostal sj^aces over this area yields a sensation 
of increased resistance when the abscess cavity is filled, which gives 
place to a sensation of markedly diminished resistance upon partial 
or complete evacuation of the purulent contents of the subjacent 
cavity. 

Numerous transient variations in the intensity of vocal frem- 
itus are encountered upon palpation of the thoracic surface over 
an extensive pulmonary abscess which occupies the periphery of 
the lung. In the cases in wiiich the abscess cavity is closed, there 
is persistent diminution or abolition of the vocal vibrations in the 
localized area of increased resistance. When, however, the abscess 
possesses a patent bronchial communication by which its puru- 
lent contents is evacuated at intervals, the variations in vocal 
fremitus are striking. Under these circumstances tactile frem- 
itus is absent over the filled cavity, and reappears in exaggerated 
form upon i3artial evacuation of the secretions of the abscess 
cavity. 

Percussion. — Pulmonary abscess involving the peripheral portion 



288 PHYSICAL DIAGNOSIS 

■ * 

of the lung yields dullness upon percussion, when it is filled, with 
hyperresonance over the adjacent areas as a result of compensatory 
emphysema of the neighboring air vesicles. When, however, the 
abscess has recently discharged a considerable portion of its puru- 
lent contents, the sound elicited by forcible percussion of the 
thorax is tympanitic or amphoric. In other words, the sounds 
elicited now are those of pulmonary excavation ; and, if the abscess 
cavity possesses a patent bronchial communication, the examiner 
may be successful in eliciting a cracked-pot sound or the phenomena 
of Wintrich, Friedreich, or Gerhardt. 

AiisciiltaUon. — In the presence of abscess of the lung, whether 
the cavity be filled or empty, auscultation of the zone surrounding 
the disease reveals the presence of numerous crepitant and sub- 
crepitant rales, which arise as a consequence of a local bronchiolar 
inflammation and pulmonary edema. If the abscess is of consider- 
able dimensions and is filled with secretions, the vesicular murmur 
is abolished over the corresponding area of the thoracic surface, 
while vocal resonance is markedly impaired in the same area. If, 
however, the abscess cavity be only partially filled, blowing bron- 
chial or amphoric breathing is encountered, together with exag- 
gerated vocal resonance upon auscultation. 

Diagnosis. — Signs of sepsis such as chills, fever, and colliqua- 
tive sweats, with copious expectoration of purulent sputum, 
combined with signs of pulmonary excavation, usually involving 
a lower lobe of the lung, following upon one of the conditions 
which may be provocative of pulmonary abscess, suggest the 
diagnosis of abscess of the lung. When a patient with lobar 
pneumonia continues to run a temperature with sweats after the 
crisis of the disease has occurred, one should think of the possible 
supervention of a purulent infiltration upon the pneumonic state. 

Thoracic pain is frequently a prominent symptom in the cases 
in which the abscess is subpleural with complicating inflammation 
of this membrane. In cases of pyemic origin signs referable to 
the small, disseminated abscesses are often obscured by the 
general symptoms of pyemia. In the later stages of the disease 
emaciation is striking, with pallor of the skin and cyanosis of 
the lips and digits, while the patient is frequently somnolent or 
delirious. When, in closed cases, a bronchus is perforated and 
copious expectoration of purulent sputum containing elastic fibers 
occurs, the diagnosis is assured. Upon perforation of the visceral 
pleura by a subpleural abscess, signs of pyopneumothorax are in 
evidence. 



DISEASES OF THE LUNGS 289 

Differential Diagnosis. — Pulmonary abscess must be differenti- 
ated from 'bronchiectasis, empyema, pulmonary gangrene, and 
chronic ulcerative phthisis. 

Bronchiectasis is attended by copious expectoration of muco- 
purulent or purulent sputum, with frequently signs of pulmonary 
excavation. The sputum of bronchiectasis, however, is free from 
elastic shreds ; and the history and course in the two affections are 
entirely dissimilar, bronchiectasis being a distinctly chronic disease 
of extensive duration and mild symptomatology, while pulmonary 
abscess is an acute disease of relatively brief duration and stormy 
course. 

Empyema of extensive duration produces signs of septic intoxi- 
cation with pallor, emaciation, chills, and sweats ; but in empyema 
the disproportion between the two sides of the thorax is more ex- 
treme ; there is demonstrable an extensive area of flatness laterally 
and posteriorly, with absence of respiratory sounds ; and the 
sputum does not contain elastic fibers. 

From pulmonary gangrene, which in its evolution also produces 
cavitation, abscess is differentiated by the absence of the extreme 
fetor of the expectoration of the former disease, a fetor which 
rapidly pervades a house or hospital ward and immediately sug- 
gests the diagnosis of gangrene. Moreover, the sputum in gangrene 
of the lung contains shreds of decomposing pulmonary tissue, which 
frequently present the characteristic structure of the alveoli of 
the lung. 

In chronic ulcerative phthisis the vomicae are prone to appear 
in the upper lobes, where they are encompassed by zones of in- 
filtrated and consolidated pulmonary tissue. Phthisis is a chronic 
disease, and bilateral disease commonly can be detected in the 
presence of cavitation. In every case repeated examinations of the 
sputum should be made for the detection of the tubercle bacillus. 

GANGRENE OF THE LUNG 

Clinical Pathology. — As invasion of the lung in which the cir- 
culation is normal by pyogenic bacteria or infectious material 
from the upper respiratory passages is apt to eventuate in 
abscess of the lung, so a similar invasion of the lung in which the 
circulation is deficient is prone to result in pulmonary gangrene. 
It is upon this impairment of the vascular integrity of the pul- 
monary tissues that rests the predisposition to pulmonary gan- 
grene in subjects of diabetes mellitus, chronic valvular disease of 
the heart, and chronic alcoholism. 



290 PHYSICAL DIAGNOSIS 

Gangrene of the lung, as first recognized by Laennec, occurs in 
two forms; namely, as circumscribed pulmonary gangrene, and as 
diffuse gangrene of the lung. The two classes of cases differ as 
widely in their mode of inception and evolution as they do in their 
physical manifestations. 

Circumscribed pulmonary gangrene has its point of inception 
in the pulmonary arteries, in the bronchi, or in cavities of bron- 
chiectatic or tuberculous origin. 

Embolic gangrene of the lung, in which infectious embolism 
arises as a result of malignant endocarditis, osteomyelitis, or sup- 
purative otitis media, is of arterial origin. In this group of cases 
the area of gangrene is situated peripherally, not infrequently 
closely subjacent to the visceral pleura. Occasionally pulmonary 
gangrene ensues upon noninfectious embolism of the pulmonary 
artery. 

Pulmonary gangrene of bronchial origin follows the lodgment of 
aspirated foreign bodies in the smaller bronchial tubes, or it ensues 
upon the aspiration into the finer bronchioles of infective material 
from the upper respiratory passages. Cohn has demonstrated that 
following the lodgment of a foreign body in the bronchial system, 
inflammation and ulceration of the mucous membrane with subse- 
quent disintegration of the bronchial wall occurs, with the es- 
tablishment of bronchiectasis, pulmonary abscess, or pulmonary 
gangrene as the concomitant factors may determine. Similarly, 
the aspiration of infective material from the upper respiratory 
passages is prone to induce an aspiration pneumonia or a putrid 
bronchitis at the area of arrestment, in which, in the words of 
Hensel, ''the putrid properties of the aspirated particles lend 
a gangrenous tendency to the catarrhal pneumonia which they 
produce." 

Gangrene of the lung arising from pulmonary excavation is 
encountered as a sequence of bronchiectasis with the accumula- 
tion of purulent secretions, chronic ulcerative phthisis with 
cavity formation, and abscess of the lung. 

Traumatism in the form of penetrating wounds of the lung has 
caused pulmonary gangrene, as has also trauma in the form of 
contusion or laceration of the pulmonary tissue without perfora- 
tion of the chest wall. 

Diffuse gangrene of the lung is an occasional terminal compli- 
cation of lobar pneumonia; but more frequently it arises as a se- 
quence of catarrhal pneumonia of the aspiration or deglutition 
type. The disease has similarly been induced by carcinoma of 



DISEASES OF THE LUNGS 291 

the lung, and it has arisen as a result of pulmonary compression 
by aortic aneurysm and mediastinal tumor. Grisolle, in an 
analysis of 305 cases of lobar pneumonia, found not a single case 
terminating in gangrene; but he noted the great constancy of 
pneumonic consolidation in the area surrounding gangrenous 
areas of the lung, consolidation which he attributed to the proxim- 
ity of the gangrenous area. 

In the circumscribed form of pulmonary gangrene the disease 
assumes either the form of a single area of pulmonary mortifica- 
tion, or of multiple areas of gangrene, separated by partially 
crepitant pulmonary tissue. The disease most frequently involves 
the inferior lobe, in which it is prone to develop in the periphery 
of the lung. In the early stage of the disease the gangrenous 
area is reddish-brown, green, or black, and is firm; but in the 
further evolution of the morbid process softening and destruc- 
tion of the pulmonary tissues occur, with the production of a 
central excavation with irregular, rugged walls, and which con- 
tains a greenish offensive fluid. In the subpleural cases the finger 
of the pathologist penetrates readily into the area of gangrenous 
tissue. In the cases in which the gangrene is more centrally 
situated, the gangrenous area is surrounded by a zone of pul- 
monary tissue which is the seat of local pulmonary congestion 
with imperfect consolidation or splenization, while adjacent to 
the area of congestion the lung is the seat of collateral edema. 

In rapidly spreading gangrene of the lung a branch of the 
pulmonary artery is apt to be eroded, eventuating in pulmonary 
hemorrhage, which may be so copious as to prove fatal. Owing 
to the usual peripheral distribution of the pulmonary lesion, the 
visceral pleura is also apt to be perforated, with the establish- 
ment of pyopneumothorax. 

Bronchitis is a constant concomitant state, as a result of the 
continuous irritation of the bronchial mucous membrane by the 
fetid contents of the gangrenous cavity. Gangrene of the lung 
is likewise occasionally associated with abscess of the brain. In 
pulmonary gangrene of bronchial origin varying degrees of 
bronchiectasis are frequently present in the lung, and pulmonary 
abscess is not infrequently complicated by gangrene of the ad- 
jacent portions of the lung. 

In pulmonary gangrene there is a rapid reduction in the erythro- 
cytes and a commensurate reduction in the hemoglobin of the 
circulating blood stream; and, in cases of pyemic origin, septi- 
cemia is not infrequently demonstrable. Leucocytosis is the 



292 PHYSICAL DIAGNOSIS 

■ * 

exception and not the rule. The course of the disease is brief 
and stormy, the subject succumbing in the vast majority of cases 
in a period varying from a few weeks to a few months from the 
onset of his disease. 

Physical Signs. — The physical signs of pulmonary gangrene 
vary with the site and the distribution of the lesions which are 
present in the lung. When the gangrenous area occupies the 
peripheral portion of the lung, and when there is active pulmo- 
nary excavation, the physical signs are those of cavity, the mani- 
festations of the disease varying naturally as the cavity possesses 
a patent bronchial communication or is closed. When, on the 
contrary, the area of gangrene is centrally situated, is devoid of 
all communication with the bronchial system, and is separated 
from the thoracic parietes by a tolerably thick bed of crepitant 
pulmonary tissue, the physical signs are anomalous or entirely 
wanting. In the majority of cases, in addition to the signs which 
are attributable to the gangrenous process, the characteristic 
signs of coexistent bronchial inflammation and partial consolida- 
tion are in evidence. 

Inspection. — The subject of pulmonary gangrene commonly pre- 
sents a picture of extreme septic intoxication. Emaciation is rapid 
and the skin is pallid, frequently with cyanosis of the lips, auricles, 
and digits. The patient is wracked by persistent paroxysms of 
cough, arising as a result of irritation of the sensitive bronchial 
mucous mambrane by the acrid contents of the gangrenous cavity. 

The patient instinctively assumes the posture in which the con- 
tents of the cavity is prevented from coming in contact with the 
mucosa of the communicating bronchi. When the gangrene attacks 
an inferior lobe of the lung, the patient is prone to assume the 
semirecumbent posture ; whereas, when the area of gangrene is 
situated in an upper lobe, the subject rests most comfortably in the 
recumbent posture with the shoulders lower than the remainder of 
the trunk. 

Hemoptysis is frequently to be noted in gangrene of the lung. 
It may consist in an admixture of traces of blood with the sputum, 
or it may occur in the form of copious pulmonary hemorrhages. 

The breath is exceedingly foul in pulmonary gangrene, a fact 
which constitutes a valuable sign of the disease when considered in 
conjunction with the sputum, which is characteristic of the condi- 
tion. The latter is abundant ; and, upon standing for several hours, 
separates into three strata : an inferior stratum composed of heavy 
or brown sediment containing shreds of elastic tissue, bacteria. 



DISEASES OF THE LUNGS 293 

blood cells, fatty-acid crystals, leucin and tyrosin ; a median layer 
composed of brown or greenish serous fluid ; and a superior stratum 
of grayish-brown froth. 

Fluoroscopy reveals the distribution and dimension of the gan- 
grenous involvement of the lung. 

Palpation. — In the subject of pulmonary gangrene the inspira- 
tory excursion of the thoracic wall is strikingly diminished; the 
respiratory movements are at the same time more frequent and 
often irregular or jerking; and the lifting power of the thoracic 
cage is practically nil. 

When, in the presence of central gangrene of the lung, the ad- 
jacent zone of infiltration and consolidation attains to the visceral 
pleura, there is frequently appreciable to the palpating hand a 
minor exaggeration of vocal fremitus, an increase which is further 
exaggerated when adhesions have been established between the 
visceral and the costal pleura. When pulmonary gangrene origi- 
nates in the cavities of chronic ulcerative phthisis, bronchiectasis, 
or pulmonary abscess, occupying the peripheral portion of the lung 
as these lesions are prone to do, tactile fremitus is markedly exag- 
gerated over the site of the lesion, and to a lesser degree over the 
adjacent zone of consolidated pulmonary tissue. 

Percussion. — The percussion findings in cases of pulmonary 
gangrene have been variable ; and, unless they are construed 
in connection with other manifestations of the disease, they are 
apt to result in confusion, especially in cases of closed or latent 
gangrene of the lung. When the gangrenous area is covered by a 
bed of densely consolidated pulmonary tissue, the examiner en- 
counters dullness upon percussion, a dull note upon which there 
is not infrequently engrafted a tympanitic quality when the gan- 
grene has resulted in pulmonary excavation. A suggestive feature 
of the dullness which attends pulmonary gangrene resides in the 
fact that the area of impaired resonance frequently extends un- 
interruptedly over an interlobar fissure, as gangrene is frequenth^ 
not limited to a single pulmonary lobe, but is prone to involve 
contiguous portions of adjacent lobes of the lung. 

Careful percussion of the thoracic surface will frequently reveal 
a zone of moderate hyperresonance surrounding the area of dullness 
which is induced by the pulmonary consolidation, a hyperresonance 
which is to be attributed to local compensatory emphysema of the 
pulmonary alveoli in these regions. 

Auscultation. — The vesicular murmur in pulmonary gangrene is 
frequently distant and feeble over the entire thorax as a result of 



294 PHYSICAL DIAGNOSIS 

■ * 

the general debility of the subject of the disease. Occasionally 
bronchial breathing is to be elicited over an area of consolidation 
or pulmonary excavation. The crepitant rale is very frequently in 
evidence as an indication of the concomitant bronchial inflamma- 
tion. 

In the presence of gangrene of the peripheral portion of the 
lung a fine pleural friction sound is occasionally to be detected, 
a rub which develops as a consequence of a complicating local 
pleuritis. 

In cases of embolic origin auscultation of the precordia not 
infrequently reveals the murmurs of coexistent valvular lesions. 

Diagnosis. — The signs and symptoms upon which the diagnosis 
of pulmonary gangrene must be based comprise progressive 
emaciation and prostration, dyspnea, elevation of temperature, 
rapid cardiac action, foulness of the breath, the suggestive decubi- 
tus of the patient, and the characteristic sputum, when it is 
present. The occurrence of hemoptysis and the detection of shreds 
of disintegrated alveolar tissue in the expectoration are determin- 
ing factors in arriving at a diagnosis. But in cases of latent pul- 
monary gangrene the breath is not foul, neither is the sputum 
characteristic, as in this class of cases the area of gangrene is 
definitely circumscribed and is devoid of any communication with 
the bronchial system. This type of the disease is prone to develop 
in diabetic and insane patients, and in these cases an error in 
diagnosis is almost certain to arise. A history of diabetes, bron- 
chopneumonia, valvular heart disease, or bronchiectasis should 
serve in some measure to place the physician upon his guard 
when interpreting obscure physical findings in a debilitated 
subject. 

Differential Diagnosis. — Mere foulness of the breath in any 
suspected case of pulmonary gangrene does not suffice to estab- 
lish a positive diagnosis, as a foul breath may result from putrid 
bronchitis, decomposition of the purulent contents of bronchiec- 
tatic cavities, or even from carious teeth, in the absence of gan- 
grene of the lung. 

In pulmonary abscess, while the sputum is abundant and puru- 
lent, the odor of the breath is sweetish rather than fetid, as in 
gangrene. Moreover, the sputum in abscess is copious, occurring 
frequently as ''mouthful expectoration;" it more frequently con- 
tains bacteria and cholesterin crystals; and shreds of alveolar 
tissue are not as abundant as in the case of gangrene. 

Chronic ulcerative phthisis with cavity formation is attended by 



DISEASES OF THE LUNGS 295 

foulness of the breath and purulent expectoration containing 
elastic fibers; but the sputum in this disease contains tubercle 
bacilli, and the foulness of the breath never approaches the stench 
of pulmonary gangrene. The vomicae of phthisis are prone to 
involve the upper lobe, and at this advanced stage of the disease 
bilateral involvement of the lungs is demonstrable. Unfortunately, 
in gangrene of the lung acid-fast bacilli closely resembling the 
tubercle bacillus morphologically are apt to be encountered in the 
sputum and to result in an erroneous diagnosis. 

In putrid 'bronchitis the breath is excessively foul; but in this 
disease the expectoration which is raised is free from elastic shreds, 
while it contains characteristic elements in the form of Dittrich's 
plugs. While the prostration attending certain cases of putrid 
bronchitis is remarkable, it does not equal that of advanced gan- 
grene of the lung. 

TUMORS OF THE LUNG 

Clinical Pathology. — Tumors of the lung may arise primarily 
in this organ, or may be secondary to tumor arising elsewhere in 
the body and implicating the lung as a result of metastasis. Of 
the two varieties of pulmonary neoplasms, the primary form is 
decidedly rare, and the secondary is the usual type of tumor of 
the lung. 

The primary tumors of the lung comprise carcinoma, sarcoma, 
and endothelioma. Carcinoma in its evolution involves usually 
one lung, where it forms a large mass, and later breaks down with 
the formation of a pulmonary cavity. But in other instances there 
develops instead a diffuse cancerous infiltration of the lung, simu- 
lating in its physical manifestations chronic ulcerative phthisis. 

The secondary tumors of the lung comprise all varieties of malig- 
nant growths. Secondary carcinoma of the lung rarely forms a 
large single tumor, but is usually multiple, and not uncommonly 
involves the pleura. The carcinomatous nodules are diffusely 
scattered over both lungs. This disease represents metastases from 
a primary tumor which may be situated in the breast, the gastro- 
intestinal tract, the genitourinary tract, or bone. Hodgkin's disease 
may affect the lung, traveling by way of the mediastinal and bron- 
chial lymphatic glands. 

Carcinoma of the lung produces swelling of the bronchial and 
mediastinal glands and occasionally of the glands of the neck. 
Pleurisy is a common complication or accompaniment of pulmonary 



296 ' PHYSICAL DIAGNOSIS 

carcinoma, and it may assume the hemorrhagic type of the disease. 

Men are affected more frequently with primary neoplasms of the 
lungs, while women are more often the victims of secondary tumors 
in this region. 

Physical Signs. — The physical signs of tumor of the lung may 
be caused by the presence of the tumor or they may be due to the 
accompanying pleural effusion, when the latter is present. In 
the latter event the signs of pleurisy with effusion overshadow 
the other signs which might be present. 

The superficial veins of the thorax and the veins of the neck 
may be tortuous and distended, owing to compression of the 
superior vena cava within the thoracic cavity. The contour of 
the thorax is altered. In the case of a very large growth there is 
unilateral bulging and widening of the intercostal spaces ; 
whereas in the case of a small growth, causing collapse of the 
adjacent pulmonary tissues, or owing to traction by adhesions, 
there is restriction of the expansion of the thorax and local de- 
pression of the chest wall. 

Vocal fremitus is occasionally exaggerated, while at other 
times it is diminished in intensity. A hyperresonant note is 
elicited upon percussion when the tumor has broken down and 
resulted in pulmonary excavation; whereas dullness or flatness 
is elicited over a large growth which involves an extensive area 
of the lung. 

The breath sounds are suppressed in many instances ; but with 
the presence of a growth of some size w^hich is superimposed upon 
a large bronchus, the breath sounds are bronchial. In the pres- 
ence of pulmonary excavation the breathing is apt to be amphoric. 

Diagnosis. — In primary cases a diagnosis is made with diffi- 
culty ; but the presence of strictly unilateral signs, attended by 
glandular enlargement, is suggestive of pulmonary neoplasm. 
The x-ray is of material aid in the diagnosis. In the case of 
carcinoma of the lung occasionally carcinomatous tissue is demon- 
strable in the sputum; and late in the course of the disease the 
growth is apt to perforate the chest wall. In a suspected case of 
pulmonary neoplasm, mediastinal tumor and aortic aneurysm 
must be eliminated. 



CHAPTER XI 
DISEASES OF THE PLEURA 

ACUTE FIBRINOUS PLEURISY (ACUTE PLASTIC PLEU- 
RISY; PLEURITIS SICCA) 

Clinical Pathology. — Acute fibrinous pleurisy, acute plastic 
pleurisy, or pleuritis sicca, occurs in a primary form and as a 
secondary disease. 

Primary acute fibrinous pleurisy is frequently noted following 
exposure to cold, particularly in patients who are debilitated by 
the excessive use of alcohol, or from other causes. Primary pleu- 
risy has also followed violent contusion of the thorax. 

Secondary acute fibrinous pleurisy occurs secondarily to dis- 
ease of the lung, notably lobar and lobular pneumonia, and 
secondarily to disease in more remote portions of the body. It 
develops in connection with tuberculosis of the lungs or of the 
bronchial glands, bronchiectasis, pulmonary infarction, and in 
abscess and gangrene of the lung. Acute fibrinous pleurisy also 
occurs as a complication of the acute exanthematous fevers and 
occasionally during the course of other acute infectious diseases. 

Among primary lesions without the lungs which may be fol- 
lowed by acute fibrinous pleurisy may be mentioned endocarditis, 
pericarditis, tonsillitis, pyorrhea alveolaris, arthritis, and typhoid 
fever. 

The inflammation usually involves the lower lateral and ante- 
rior portions of the pleura, in which site it may be localized to a 
very limited area, or it may involve the greater portion of the 
visceral pleura. Under the influence of the inflammatory process 
the pleura becomes dull and lusterless, with a rather granular, 
irregular surface. The membrane is thickened and the surface is 
covered with one or more layers of fibrinous exudate. During 
the movements of respiration the exudate is apt to be rolled into 
folds upon the surface of the pleura, or it may be thrown up into 
exuberant masses. There is a small amount of cloudy fluid exud- 
ing from the inflamed surface; but it never attains the degree 
which is seen in serofibrinous pleurisy or pleurisy with effusion. 

Microscopically, the pleura presents desquamation and degen- 

297 



298 PHYSICAL DIAGNOSIS 

eration of the covering endothelium at the site of the inflamma- 
tion, patches of the pleura being found entirely devoid of 
endothelial covering. At the same time, the subserous connective 
tissue layer of the membrane is edematous and exhibits a variable 
degree of leucocytic infiltration. The vessels in the zone of the 
inflammation are dilated and are filled with erythrocytes. Upon 
microscopic examination of the exudate which is thrown out, it 
is found to contain fibrin, serum, and a variable number of pus 
cells. 

In cases of acute fibrinous pleurisy of extensive duration the 
visceral and parietal layers of the pleura not infrequently become 
adherent, impairing the movement of the lung to a variable ex- 
tent during respiration. 

Physical Signs. — Inspection. — In acute fibrinous pleurisy the 
respirations are moderately accelerated and are apt to be jerky and 
irregular. The thoracic expansion upon the side of the disease is 
limited, and the diaphragmatic shadow is abolished. The trunk is 
commonly inclined toward the side of the disease, with slight 
drooping of the corresponding shoulder. 

Palpation. — Palpation of the thorax reveals in many instances 
pleural friction fremitus, which is produced by the rubbing to- 
gether of the roughened surfaces of the visceral and parietal pleurae. 
If the pleural inflammation involves the portion of the visceral 
pleura which overlies the pericardium, the friction fremitus as- 
sumes the pleuropericardial type. Vocal fremitus seldom presents 
any alteration in acute plastic pleurisy ; but, if there is considerable 
pleural thickening, the intensity of the vocal vibrations is dimin- 
ished over the area of the disease. Palpation confirms the presence 
of minor deficiencies of expansion of the affected side of the thorax. 

Percussion. — The note which is elicited upon percussion of the 
thorax over an area of acute fibrinous pleurisy in an initial attack 
of the disease betrays no departure from normal pulmonary reso- 
nance ; but, in the case of repeated attacks, there may be sufficient 
pleural thickening to cause moderate impairment of resonance upon 
the side of the disease. Percussion of the inferior pulmonary bor- 
ders during inspiration yields a pertinent sign of the disease in the 
limitation of the respiratory excursion of the diseased lung. Pain 
is not infrequently elicited upon percussion in this disease. 

Auscultation. — Auscultation over the site of the disease reveals 
the pathognomonic sign of the disease, the pleural friction sound; 
and, in suitably placed lesions, pleuropericardial friction. The 
vesicular murmur is retained, but its intensity is diminished upon 



DISEASES OF THE PLEURA 299 

the side of the disease as a result of the pain which attends full 
inspiration. In the presence of considerable pleural thickening the 
murmur is abolished over the site of the thickened pleura. Vocal 
resonance is as a rule unchanged ; but in the presence of excessive 
pleural thickening, its intensity is diminished. 

Diagnosis. — The pleural friction sound, when it is elicited, is 
pathognomonic of acute fibrinous pleurisy. The disease is also 
attended by moderate fever and by darting, stabbing pain, which 
is most commonly referred to the region of the axilla or the nipple, 
and which is accentuated by coughing and by deep inspirations, 
signs which are not pathognomonic of the disease. 

Differential Diagnosis. — Pleurodynia is attended by pain in the 
side, but the pain of this disease is continuous and is aggravated 
by movement of the trunk as well as by the movements of respira- 
tion. Moreover, there is absence of the friction sound and the 
localization of the pain is not as distinct and clear-cut as it is in 
pleurisy, the pain occasionally ceasing upon one side of the thorax 
to appear upon the opposite side of the chest. Pleurodynia is not 
attended by febrile movement. 

Intercostal neuralgia is characterized by sharp, paroxysmal pain 
over the distribution of the nerve trunks. In this condition there 
are points of tenderness upon palpation over the points of exit of 
the nerves upon the lateral and anterior chest walls. Developing 
as the disease does most frequently upon a neurotic basis, pleural 
friction and fever are absent in intercostal neuralgia. 

SEROFIBRINOUS PLEURISY (PLEURISY WITH EFFUSION; 
PLEURITIS EXUDATIVA) 

Clinical Patholog*y. — Serofibrinous pleurisy, pleurisy with effu- 
sion, or pleuritis exudativa, frequently folloAvs exposure to cold 
or a severe wetting, Avhen it is attributed to an attack upon the 
pleura by organisms which are present in the bodily economy; 
but in certain instances exposure is the only apparent cause of 
the disease. 

Lobar pneumonia, by involving the pleura over a consolidated 
lobe, often causes serofibrinous pleurisy; but there is occasionally 
seen a primary pleurisy with effusion which is caused by the 
pneumococcus and which arises independently of disease of the 
lung. Serofibrinous pleurisy is an occasional complication of 
nephritis and acute rheumatic fever, in which it is due either to 
the associated toxemia or to the bacteria which are associated 
with these diseases. 



300 PHYSICAL DIAGNOSIS 

The organism which is most frequently associated with sero- 
fibrinous pleurisy is the tubercle bacillus. In these cases the 
tuberculous focus may be situated in the lung or in a distant 
portion of the body. The streptococcus pyogenes is the causative 
agent in certain cases of serofibrinous pleurisy, with or without 
the coincident development of a streptococcic bronchopneumonia. 
In the female subject pleurisy with effusion has developed in 
subjects with tuberculous salpingitis. 

Pleurisy with effusion attacks males with greater frequency than 
females, usually attacking persons between twenty and fifty years 
of age, though no age is exempt from the disease. 

In serofibrinous pleurisy there is an initial dulling and loss of 
luster with roughening of the surface of the pleural membrane ; 
and this is succeeded in a few hours by the exudation of a sero- 
fibrinous exudate. In a period varying from a few hours to 
several days there is more or less copious exudation of serous 
fluid from the surface of the inflamed pleura. 

The fluid gravitates to the dependent portions of the pleural 
sac, and mounts up higher and higher as the effusion develops. In 
certain instances the effusion becomes so excessive that it reaches 
the level of the clavicle. The lung, which is compressed by the in- 
creasing fluid, is crowded into the upper and posterior portions of 
the pleural cavity, occupying a comparatively small area in the 
upper portion of the cavity near the vertebral column. 

The effusion consists of straw-colored fluid possessing a 
specific gravity of approximately 1,020, containing flocculi of 
fibrin together with numerous desquamated endothelial cells, pus 
cells, bacteria and blood cells. Upon withdrawal of the fluid, 
spontaneous coagulation is occasionally noted. The solid con- 
stituents of the effusion occupy the dependent portion of the 
pleural sac, and the fibrinous material adheres to the surface of 
the pleura, in which position when the fluid is absorbed or is 
withdrawn, it aids in the formation of fibrous adhesions between 
the visceral and the parietal pleura. 

These adhesions vary in distribution in individual cases. In 
certain instances they are relatively few and are local; in other 
cases they are universally distributed over the entire pleura ex- 
cept for a pocket here and there; while in yet other instances 
they may obliterate the pleural sac entirely, resulting in chronic 
adhesive pleurisy. When a patient with numerous adhesions has 
a second attack of serofibrinous pleurisy, only the nonadherent 



DISEASES OF THE PLEURA 301 

portions of the membranes are involved, with the formation of a 
loculated, sacculated, or encysted pleurisy. 

In serofibrinous pleurisy the amount of the effusion varies 
from a few ounces to four liters. After pursuing a variable 
course, it tends to spontaneous absorption, often leaving exten- 
sive pleural adhesions in its wake. 

In cases of serofibrinous pleurisy which are associated with 
excessive effusion, there is visceral displacement. The liver or 
the spleen is displaced downward and tlie heart is displaced 
toward the side opposite the effusion. 

Physical Signs. — Inspection. — In serofibrinous pleurisy the res- 
piratory excursion upon the side of the effusion is restricted or is 
abolished. With all large effusions there is unilateral bulging of 
the chest wall and the intercostal spaces are obliterated upon the 
side of the disease. Litten's diaphragmatic shadow is absent. 

In effusions of the right pleural sac the cardiac impulse is 
displaced toward the left, and is occasionally elevated to the 
fourth interspace. It is not infrequently localized in the left 
midclavicular line, or even in the left axillary region. In the 
case of left-sided effusion, on the other hand, the cardiac impulse 
is displaced toward the right, and it often occupies a position 
behind the sternum. In extreme cases, however, the apex beat 
may be visible to the right of this bone in the third or fourth 
intercostal space. 

The respirations are shallow and accelerated, as a result of 
compression of the lung by the effusion, with consequent diminu- 
tion in the air space. There is visible scoliosis, the vertebral 
column deviating toward the side of the effusion. The sound 
side of the thorax expands vicariously during inspiration as a 
result of compensatory emphysema. 

The decubitus of the patient is not infrequently suggestive in 
serofibrinous pleurisy. During the incipient stage of the disease, 
prior to the pouring out of the effusion, the patient is apt to lie 
upon the sound side in the effort to protect the sensitive pleura 
from pressure, while, after the effusion is established, he usually 
lies upon the side of the effusion in order to facilitate the full 
expansion of the sound lung. The shoulder upon the side of the 
effusion is upon a slightly higher level than is its fellow. Simi- 
larly, the nipple and the scapula upon the side of the effusion 
are farther from the median line than on the opposite side of the 
thorax. 

Palpatio}!. — During the incipient stage of the disease, prior to 



302 PHYSICAL DIAGNOSIS 

■ * 

the development of the effusion, palpation of the thorax reveals 
the presence in most cases of pleural friction fremitus. If, indeed, 
the lappet of lung which overlies the heart is involved, there is 
pleuropericardial friction fremitus. Friction fremitus is demon- 
strable during the incipient, dry stage of the disease; it usually 
disappears with the development of the effusion; and it reappears 
with the absorption or after the withdrawal of the fluid. Yet not 
infrequently friction fremitus can be detected during the height 
of the effusion along its upper level, where the inflamed pleural 
membranes come in contact. The friction fremitus not infrequently 
persists for years after recovery from the disease, as many subjects 
of the disease can attest. 

Vocal fremitus varies according to the degree of the associated 
effusion. In the presence of moderate effusion, which does not 
fill the pleural sac, vocal fremitus is normal above the level of the 
effusion, while over the area corresponding to the effusion it is 
abolished. Posteriorly, near the vertebral column, over the area 
which is occupied by the compressed lung, vocal fremitus at the 
height of the effusion is apt to show exaggeration. In interpreting 
the intensity of vocal fremitus in this disease it must be borne in 
mind that dense pleural adhesions traversing a pleural effusioil 
will and do transmit the vibrations to the palpating hand despite 
the presence of fluid in the pleural sac. 

Palpation of the precordia confirms displacement of the apex- 
beat, and palpation of the lateral thoracic regions shows deficient 
expansion of the diseased side. There is seldom edema of the chest 
wall in serofibrinous effusion, this sign being more commonly pres- 
ent in purulent effusions. In effusion of the right pleural sac pal- 
pation reveals the inferior border of the liver at an abnormally low 
level below the right costal margin. 

Percussion.- — During the incipient stage of serofibrinous pleurisy 
the percussion note is unchanged. In the further evolution of the 
disease, however, as the effusion develops, there is a progressive 
im.pairment of vesicular resonance, finally amounting to flatness 
over the effusion. Percussion of the thorax immediately above the 
level of the effusion elicits Skodaic resonance. 

With the patient in the upright posture, Ellis' line of flatness, 
indicating the upper limit of the effusion, can occasionally be 
mapped out by percussion. In pleurisy with effusion this line, 
which represents the upper limit of the effusion is not horizontal; 
it is higher posteriorly than anteriorly ; and in effusions of moder- 
ate degree the line begins low down in the posterior region of the 



DISEASES OF THE PLEURA 303 

thorax and proceeds upward and forward in a cnrve resembling 
the letter ^'S" to the axillary region, and thence proceeds in a 
gradual decline to the sternum. 

Grocco's triangle of paravertebral dullness is demonstrable in 
most cases of serofibrinous pleurisy. This triangular area, with a 
width of two to five centimeters, with its apex directed upward, 
occupies the side of the thorax opposite the effusion at the level of 
the 11th and 12th ribs. It is probably due to displacement of the 
mediastinal structures by the pressure of the effusion. (See Fig. 
53, p. 128.) 

In right-sided effusion the dullness of the fluid blends ante- 
riorly and laterally with the dullness of the liver; w^hereas an 
effusion of the left side encroaches upon the tympany of Traube 's 
semilunar space. In serofibrinous pleurisy it is only occasionally 
possible to detect movable dullness upon change of posture. While 
not always present in this disease, movable dullness when elicited 
is an infallible sign of fluid in the pleural cavity. 

Forcible percussion over the upper portion of the lung, above 
the level of the effusion, occasionally elicits a cracked-pot sound, 
produced by the sudden forcible expulsion of air from the re- 
laxed lung. Similarly, upon strong percussion over the infra- 
clavicular region in the presence of large effusions, Williams' 
tracheal tone may sometimes be elicited. 

During absorption of the effusion the dullness gradually is 
superseded by normal vesicular resonance, save at the bases 
posteriorly, where the resonance is apt to remain impaired for a 
long period. Areas of impaired resonance elsewhere point to 
areas of pleural thickening or to encysted fluid. 

Auscultation. — In the incipient stage of the disease, prior to the 
development of effusion, a pleural friction sound is frequently 
audible upon auscultation. It is usually best detected in the lower 
axillary or mammary region. The friction sound usually though 
not invariably disappears at the height of the effusion, to become 
once more audible with the inception of absorption of the effusion. 
When the portion of the pleura which overlies the pericardium is 
involved, a pleuropericardial friction sound is audible. 

The vesicular murmur is abolished over the area of the thorax 
which overlies the effusion, while above the effusion, the respiratory 
sounds are puerile. While this statement as a rule holds true, yet 
in very large effusions there is occasionally distant bronchial 
breathing over the effusion, due to the dense compression of the 
lung by the fluid which occupies the pleural cavity. The respi- 



304 PHYSICAL DIAGNOSIS 

" * t 

ratory murmur over the sound lung is exaggerated as a result of 
compensatory emphysema. 

Vocal resonance over the effusion is abolished, unless a patch 
of pleura be bound to the chest wall by adhesions, in which event 
the resonance is of approximately normal intensity in the area in 
question. Upon auscultation just above the level of the effusion 
during phonation, particularly near the angle of the scapula poste- 
riorly, egophony is frequently elicited. Baccelli's sign, the trans- 
mission of the whispered voice through a serous while not through 
a purulent effusion serves to differentiate the latter condition from 
the former. 

Upon auscultation of the heart, the sounds are often rather 
diffusely audible, owing to cardiac displacement. The pulmonic 
sound is usually accentuated and a systolic murmur may be audible, 
which is produced by traction upon the vessels by the cardiac 
displacement. 

Mensuration. — Mensuration of the thorax reveals an increase in 
the circumference of the diseased side of from one-half to one and 
one-half inches. In interpreting the findings of mensuration al- 
lowance must be made for the fact that the right half of the thorax 
is normally larger than is the left side. 

Diag"nosis. — The diagnosis of serofibrinous pleurisy rests upon 
the deficient expansion and frequently the unilateral bulging of 
the diseased side, the presence of the initial friction sound which 
disappears with the advent of effusion, the absence of vocal frem- 
itus over the effusion, the flat percussion note over the fluid, the 
absence of respiratory sounds over the effusion, with the presence 
of puerile or bronchial sounds elicited above the level of the 
fluid, and the presence of visceral displacement, together with 
certain special phenomena such as bronchophony, egophony, or 
Baccelli's sign. The presence of fluid in the pleural cavity and 
its character are determined by exploratory puncture. But 
exploratory puncture does not in every positive case reveal the 
presence of fluid. Even if the needle is inserted in an area of 
flatness, it may penetrate a region where a thickened pleura is 
adherent to the chest wall and so fail to secure fluid, though 
fluid is present. 

Differential Diagnosis. — Serofibrinous is occasionally differenti- 
ated from lobar pneumonia with difficulty. The points of differ- 
entiation between these diseases have been enumerated under 
lobar pneumonia. 

From large pericardial effnsion, serofibrinous pleurisy is some- 



DISEASES OF THE PLEURA 305 

times differentiated with difficulty, particularly in the cases of 
effusion into the left pleural cavity. But in pericardial effusion 
the base of the lung yields resonance instead of flatness; there is 
Skodaic resonance over the adjacent portion of the lung which is 
compressed by the effusion; the cardiac impulse is not displaced 
to the right ; the heart sounds are feeble ; the pulse is apt to be of 
the pulsus paradoxus type, trailing off toward full inspiration ; and 
the degree of dyspnea is extreme and out of proportion to the 
extent of the effusion. Moreover, in pericardial effusion the area 
of dullness occupies the precordia and is pear-shaped with the base 
resting upon the diaphragm. 

Unilateral hydrothorax presents physical signs which are largely 
identical with those of serofibrinous pleurisy. But in hydrothorax 
there is absence of the initial friction sound; there is no primary 
stitch in the side, or fever, but instead there is a history of heart 
disease, or of nephritis. Moreover, hydrothorax is frequently at- 
tended by edema of dependent portions of the body. 

Ellis' curve is not present in hydrothorax and upon exploratory 
puncture the fluid of hydrothorax is more serous, and is of lower 
specific gravity ; it contains less than three per cent of albumin ; 
and it never coagulates spontaneously upon standing. In hydro- 
thorax movable dullness is usually readily elicited, as the fluid of 
hydrothorax readily shifts with change of posture, while in pleu- 
risy with effusion this sign is elicited with difficulty if, indeed, it 
is elicited at all. 

Intrathoracic neoplasms may simulate serofibrinous pleurisy. 
They frequently produce displacement of the cardiac impulse, as 
does pleurisy with effusion. The dullness of neoplasm, however, 
occupies the upper portion of the thorax and is of minor extent, 
and it is surrounded by a zone of compressed lung, yielding 
Skodaic resonance. Vocal fremitus and vocal resonance are in- 
creased rather than diminished. The breath sounds are fre- 
quently suppressed, and at other times distinctly bronchial. Pul- 
monary neoplasm often coexists with moderate pleural effusion. 
Malignant neoplasms are prone to produce glandular enlarge- 
ment in the supraclavicular region, and are eventually attended 
by emaciation and cachexia. These growths also cause enlarge- 
ment of the mediastinal glands, producing in this wise pressure 
paralysis of the recurrent laryngeal nerves. Moreover, in the 
case of neoplasm, the physical signs are not influenced by change 
of posture. 

Hepatic enlargement from abscess, echinococcus cyst, or enlarge- 



30b PHYSICAL DIAGNOSIS 

f 

■ « 

ment from subphrenic abscess may simulate pleurisy with effusion. 
But the upper limit of dullness is immovable ; it presents a convex 
outline directed upward ; and it frequently exhibits a friction 
sound in the midst of the area of dullness, which would not be true 
if the pleural surfaces were separated by effusion. These condi- 
tions are not infrequently attended by moderate pleural effusion 
and hence coexistent therewith. Upon exploratory puncture the 
pus from an hepatic abscess may perhaps contain liver cells or 
bile, and occasionally amebse. Grocco's sign is absent in hepatic 
enlargement. Occasionally hydatid fremitus may be elicited upon 
percussion over an echinococcus cyst of the liver. 

PneumotJiorax produces unilateral bulging of the thorax with 
immobilization ; but the percussion note is hyperresonant or tym- 
panitic; and the disease is attended by characteristic physical 
signs, as the coin test, the metallic tinkle, and the succussion sound. 

LOCAL PLEURISY 

Under the head of local or circumscribed pleurisy are embraced 
diaphragmatic pleurisy; loculated, saccidated, or encysted pleurisy; 
and interlobar pleurisy. 

DIAPHRAGMATIC PLEURISY 

Clinical Patholog-y. — In diaphragmatic pleurisy the inflamma- 
tion is limited to the parietal pleura which invests the superior 
surface of the diaphragm and to the visceral pleura which is in 
contact with it. 

The pleural inflammation as a rule assumes the dry, plastic 
type ; but there is sometimes moderate effusion, which may be 
serous or purulent in character. 

Physical Sig"ns. — The physical signs of diaphragmatic pleurisy 
are slight in comparison with the subjective symptoms, which 
are unusually severe in their manifestations. There is urgent 
dyspnea; and the lower region of the thorax is fixed, moving 
very slightly with respiration. A friction sound can occasionally 
be elicited over the hepatic area in right pleural inflammation, or 
over Traube's semilunar space in left-sided inflammation. 

There is tenderness upon pressure upon the lower intercostal 
spaces near the vertebral column, and extreme pain upon pres- 
sure over the insertion of the diaphragm at the tenth rib. There 
is occasionally tenderness upon pressure over the course of the 



DISEASES OF THE PLEURA 307 

phrenic nerve in the cervical region. Dysphagia is occasionally 
present, as a result of involvement of the esophageal orifice in 
the diaphragm; and hiccough and vomiting may accompany left- 
sided diaphragmatic pleurisy. The vomiting and respiratory 
movements exaggerate the pain of the disease. Pain is constant 
in the epigastric region, simulating in this respect acute disease 
of the abdominal viscera. The diaphragm is fixed, and the res- 
piration is purely costal in type. 

Diagnosis. — The diagnosis of diaphragmatic pleurisy rests upon 
the great severity of the subjective symptoms and the meagerness 
of physical signs. Gueneau de Mussy states that pain extending 
from the tenth rib to the ensiform cartilage is pathognomonic of 
diaphragmatic pleurisy. Andral has noted cases attended by 
excessive dyspnea and attacks simulating angina pectoris. 

LOCULATED, SACCULATED, OR ENCYSTED PLEURISY 

Clinical Pathology. — This type of pleurisy may be serofibrin- 
ous, but is more frequently purulent. In this form of pleurisy 
the fluid is circumscribed by adhesions between the visceral and 
parietal pleurae into one or more pockets or loculi, which may 
or may not communicate with one another. While these loculi 
of effusion may develop in any portion of the pleural cavity, they 
are most frequently situated in the region between the midaxil- 
lary line and the midspinal line, or upon the thoracic aspect of 
the diaphragm. In these cases the fluid may be bounded by ad- 
hesions, the result of a previous attack of pleurisy; or an em- 
pyema may become limited and circumscribed by newly formed 
inflammatory adhesions. 

Physical Signs. — The physical signs in this type of pleurisy 
are few and are frequently atypical. Areas of dullness may be 
elicited in certain cases; but this is by no means the rule; and 
vocal fremitus may be clearly transmitted by the adhesions 
despite the presence of fluid in the pleural cavity. Fluoroscopy 
and the free use of the aspirating needle are the surest means of 
diagnosis. 

INTERLOBAR PLEURISY 

Clinical Pathology. — In the evolution of seroflbrinous or puru- 
lent pleurisy the pleura clothing the interlobar fissures of the 
lung is also implicated in the inflammation, and not infrequently 



308 PHYSICAL DIAGNOSIS ' 

■ * 

becomes adherent, enclosing between the two pleural layers a 
variable quantity of serofibrinous or purulent fluid. 

Also in cases of lobar pneumonia and pulmonary tuberculosis 
an interlobar pleurisy may occur, with adhesions of the pleural 
surfaces and retention of effusion. Interlobar pleurisy is usually 
purulent, and in its physical manifestations it frequently closely 
simulates pulmonary abscess. Such a collection of pus may 
perforate and discharge into a bronchus and lead to the expecto- 
ration of purulent sputum. 

Interlobar pleurisy develops with the greatest frequency near 
the root of the right lung, involving the pleura which dips into 
the fissure between the upper and middle lobes of the lung. 

Physical Signs. — The physical signs of interlobar pleurisy are 
frequently atypical and confusing. As a rule, there is little or 
no dullness upon percussion; but in certain cases a zone of dull- 
ness corresponding to the course of the fissure between the upper 
and middle lobes of the right lung can be found, limited above 
and below by a zone of Skodaic resonance. 

Diagnosis. — The x-ray is of aid in the diagnosis. Aspiration is 
dangerous, as the lung is apt to be infected during withdrawal of 
the needle. The clinical picture frequently closely simulates that 
of pulmonary abscess. 

PURULENT PLEURISY (EMPYEMA) 

Clinical Pathology. — Purulent pleurisy or empyema occurs in 
rare instances as a primary disease, chiefly in young infants; but 
in the vast majority of cases it is secondary to disease or injury 
of the lung or thorax. 

Purulent pleurisy complicates many acute infectious diseases, 
as scarlatina, lobar or lobular pneumonia, and pulmonary tuber- 
culosis; and it may be a sequela of abscess or gangrene of the 
lung. It may be caused by penetration of the chest wall by a 
fractured rib or by other perforating wound. Perforation of the 
diaphragm by subphrenic abscess is frequently followed by em- 
pyema ; and carcinoma of the esophagus is prone to penetrate the 
pleura and may be productive of empyema. 

While it is quite possible by secondary infection for a primarily 
serous pleural effusion to become purulent, yet empyema is usu- 
ally purulent from the outset of the disease. The pneumococcus 
is responsible for the greater number of cases of empyema, either 
having its inception as lobar pneumonia, or attacking the pleura 



DISEASES OF THE PLEURA 309 

primarily. Next in the order of their frequency come the pyo- 
genic micrococci, the tubercle bacillus, the bacillus influenzae and 
the colon bacillus. Empyema is especially frequent in young 
children, although no age is exempt from the disease. 

In purulent pleurisy the pleural cavity contains a variable 
amount of pus, which is frequently quite large, often amounting 
to two or more liters. The solid constituents of the purulent 
effusion gravitate toward the dependent portions of the pleural 
sac, Avhile the upper strata consist of turbid fluid. This fact may 
be productive of an error in diagnosis ; because, if the aspirating 
needle is entered above the level of the distinctly purulent 
stratum, only turbid fluid may be withdrawn, suggesting the 
presence of a serofibrinous effusion. While the separation of the 
fluid into two strata obtains during the early stage of the effusion, 
yet in cases of long standing the fluid is uniformly thick and 
purulent and contains shreds of flbrin. Depending upon the 
character of the infecting organism the pus may be odorless or 
may be extremely fetid. 

In the evolution of the disease, subsequent to the development 
of the purulent effusion, the tendency is toward spontaneous ab- 
sorption; and it is possible for the effusion to be absorbed in its 
entirety. Following absorption of the effusion the pleura under- 
goes thickening from organization of the fibrinous layer with 
which it is clothed, tending to impair the transmission of sounds 
arising within the lung. The pleural thickening is most pro- 
nounced in the visceral layer of this membrane. 

Pleural adhesions are almost invariably present in empyema, 
which may represent the remnants of a former pleurisy, or which 
may be of recent formation, serving to circumscribe the effusion 
into one or more pockets or loculi. They are situated principally 
over the upper portions of the lung, probably because this por- 
tion of the pleura is in contact, while the lower portion is sepa- 
rated by the effusion. The adhesions may be limited, or they may 
be numerous, extending well down toward the base of the lung. 

Purulent pleurisy is constantly attended by changes in the lung. 
The effusion occupies space in the pleural cavity which was pre- 
viously occupied by the lung, so that this organ is compressed, and 
its expansion is materially restricted. This tends toward con- 
densation and atelectasis of the lung, and in large effusions the 
lung occupies a small portion of the pleural cavity near the verte- 
bral column. In the further evolution of the disease the lung 
becomes splenized, and finally cirrhotic, airless, and of dark color. 



310 PHYSICAL DIAGNOSIS 

The heart is displaced by the effusion, and the impact of this 
organ against the fluid during ventricular systole causes ''pulsat- 
ing empyema." The liver and spleen are apt to be displaced 
downward. 

Extensive purulent pleurisy produces permanent deformity of 
the thorax. As the effusion accumulates, the side of the thorax 
corresponding to the disease bulges, and the intercostal spaces are 
obliterated or actually bulge from the pressure which is exerted 
upon the intercostal muscles. The diaphragm is depressed and its 
excursion is limited, resulting in an increase in the vertical diam- 
eter of the thorax. Following the absorption or evacuation of the 
purulent effusion, the intercostal spaces are retracted, and the 
side of the thorax corresponding to the disease partially collapses, 
the shoulder droops, and the spinal column is bowed toward the 
side of the disease. 

The pus of empyema is apt to burrow beneath the costal pleura 
and to point subcutaneously, constituting ''empyema necessita- 
tis." Spontaneous evacuation of the effusion is apt to occur, un- 
less it is relieved by prompt aspiration. Or, on the other hand, 
the pus may perforate the visceral pleura and discharge into a 
bronchus, with the production of pyopneumothorax. 

Physical Signs. — Inspection. — The physical signs of purulent 
pleurisy which are noted upon inspection are in the main very 
similar to those of serofibrinous pleurisy; but the diseased side 
presents a greater degree of unilateral bulging, and there is more 
apt to be bulging of the intercostal spaces, particularly over the 
lower regions of the thorax. Edema of the chest wall is noted when 
the parietal pleura is extensively involved, and in empyema neces- 
sitatis there is visible protrusion of a localized region of the chest 
wall with discoloration of the integument when rupture is immi- 
nent. The cardiac impulse is displaced toward the opposite side 
of the thorax, and the Aveight of the purulent effusion produces 
downward displacement of the diaphragm, with consequent down- 
ward displacement of the liver, which may produce bulging be- 
low the right costal margin. The subcutaneous veins of the tho- 
rax are apt to be tortuous over the lower thorax ; and the dia- 
phragmatic shadow is abolished upon the side of the effusion. In 
pulsating empyema there is systolic pulsation which is synchron- 
ous with the cardiac systole. 

Palpation. — Vocal fremitus is abolished over the distribution 
of the purulent effusion, while above the level of the fluid, over 



DISEASES OF THE PLEURA 311 

the compressed lung, the fremitus is occasionally exaggerated. 
Pulsating empyema yields a palpable systolic pulsation, while in 
empyema necessitatis the edematous chest wall may pit upon 
pressure with the finger-tips. 

Percussion. — There is dullness amounting to flatness over the 
purulent effusion, with Skodaic resonance above the level of the 
fluid, as in serofibrinous pleurisy. Percussion of the opposite lung 
yields a slightly hyperresonant note as the result of compensatory 
emphysema. Grocco's triangular area of paravertebral dullness 
is usually well-marked in empyema. 

Auscultation. — The respiratory murmur is abolished over the 
purulent effusion, while it is puerile over the compressed lung 
above the level of the effusion. In children there is frequently 
blowing bronchial breathing above the level of the fluid. 

Diagnosis. — -Purulent pleurisy closely resembles serofibrinous 
pleurisy in its physical manifestations ; but in empyema the dis- 
proportion between the two sides of the thorax is more marked ; 
there is more apt to be intercostal bulging in empyema ; and the 
visceral displacement in purulent pleurisy is more extreme. 
Edema of the thoracic wall points to purulent rather than to 
serofibrinous pleurisy. Moreover, empyema is attended by a 
greater degree of dyspnea than is serofibrinous effusion, the la- 
bored breathing frequently amounting to orthopnea. Purulent 
pleurisy is attended by less local pain than is serofibrinous pleu- 
risy ; but there are in empyema greater emaciation and signs of a 
generally septic state. Aspiration reveals the presence of puru- 
lent effusion in the pleural cavity. Baccelli's sign is occasionally 
of aid in the differential diagnosis. 

CHRONIC ADHESIVE PLEURISY 

Clinical Pathology. — Chronic adhesive pleurisy, or chronic plas- 
tic pleurisy is most frequently a sequence of serofibrinous pleurisy, 
more rarely of empyema, and occasionally it develops as a pri- 
mary affection of the pleura. , 

Following the aspiration or absorption of a pleural effusion of 
the serofibrinous or purulent type, the surface of the pleura is 
covered with an exudate which is rich in fibrinous elements and 
moreover there are usually scattered areas in Avhich the surface 
endothelium has desquamated, exposing the subjacent connec- 
tive tissue basis of the pleural membrane. The surfaces of the 



312 PHYSICAL DIAGNOSIS 

visceral and the parietal pleura, coated as they are with fibrinous 
exudate, have a tendency to adhere to one another; and, the fibrin- 
ous exudate having undergone organization, the two surfaces be- 
come bound together by fibrous adhesions of variable extent. In 
extreme cases the surfaces may adhere throughout their entire 
extent, obliterating the potential pleural cavity, and restricting 
the respiratory excursion of the lung. 

Physical Signs. — The physical signs of chronic adhesive pleu- 
risy vary with the duration of the disease and with the extent of 
the pleural adhesions, varying from moderate dyspnea to extreme 
embarrassment of the respiratory function and striking thoracic 
deformity. 

Inspection. — In cases of chronic adhesive pleurisy with moder- 
ate adhesions slight dyspnea may be the only sign of the disease, 
and even this sign may not be in evidence. But in the more ex- 
treme grade of the disease, in which numerous adhesions between 
the visceral and the parietal pleura bind the lung to the thoracic 
wall, local retraction or absolute immobilization of the correspond- 
ing side of the thorax is in evidence. 

Palpation. — Upon palpation of the thorax pleural friction frem- 
itus is demonstrable over the sites of pleural roughening and thick- 
ening. Palpation is apt to detect minor degrees of expansion 
and thoracic retraction in cases of moderate adhesions. In cases 
with considerable thickening of the pleura the intensity of vocal 
fremitus is diminished. 

Percussion. — The percussion note is but little altered in cases of 
moderate pleural involvement; but the note is strikingly dull and 
the resistance to the pleximeter is marked in cases with oblitera- 
tion of extensive portions of the potential pleural cavity. The 
respiratory excursion of the lung is greatly diminished, occasion- 
ally to complete immobilization, upon the side of the disease. The 
note upon percussion of the opposite lung in the extreme case is 
hyperresonant as a consequence of compensatory emphysema. 

Auscultation. — In chronic adhesive pleurisy the respiratory 
murmur is very apt to be enfeebled over various areas or indeed 
in the extreme case over the entire side of the thorax. Over 
areas of pleural roughening the pleural friction sound is audible; 
and very frequently the rales of an associated chronic bronchitis 
are audible upon the side of the disease. 

Diagnosis. — The diagnosis is made upon the presence of the 
pleural friction sound, the thoracic deformity and respiratory em- 
barrassment, with a history of previous acute pleurisy. 



DISEASES OF THE PLEURA 313 

HEMOTHORAX 

Clinical Patholog-y. — The collection of blood in the pleural cav- 
ity may result from rupture of an aneurysm of one of the larger 
intrathoracic arteries or from erosion of an intercostal vessel in 
the presence of pleural disease. Hemothorax also arises as a 
result of trauma to the chest wall, notably after perforating 
wounds from missiles or from a fractured rib. Gangrene of the 
lung may be responsible for the hemorrhage, or it may be a por- 
tion of a hemorrhagic diathesis. Eupture of aneurysm of the 
aorta usually produces hemothorax of the left pleural cavity. 

The onset of hemothorax is usually very abrupt, and if one of 
the larger intrathoracic vessels is the source, it is usually rapidly 
fatal. In bleeding from an intercostal vessel the bleeding is apt 
to be slowly continuous for a variable time, after which it spon- 
taneously ceases. 

The amount of blood which is extravasated into the pleural 
cavity is variable. If infection does not occur, following arrest of 
the hemorrhage, complete absorption may occur; not, however, 
without leaving pleural adhesions. 

Physical Sig'ns. — The initial signs of hemothorax are those of 
internal hemorrhage ; namely, pallor, with dyspnea, rapid pulse, 
and collapse. Superimposed upon these signs are those of effusion 
in the pleural cavity; and exploratory puncture reveals the pres- 
ence of sanguineous fluid. 

CHYLOTHORAX 

Clinical Pathology. — Effusion of chyle or chyliform fluid into 
the pleural cavity is only occasionally encountered. The fluid may 
be derived from rupture of the thoracic duct or may be discharged 
by transudation from the lacteals. The thoracic duct may be rup- 
tured by trauma to the thorax ; or the duct may be obstructed by 
the pressure of an intrathoracic tumor. Again, a chylous ascites 
may discharge into the pleural cavity by way of the lymphatics. 
Or, again, occlusion of the left subclavian vein, into which the thor- 
acic duct empties its contents, may result in chylothorax. 

Physical Signs. — The physical signs of chylothorax are essen- 
tially those of fluid in the pleural cavity. The nature of the effu- 
sion is determined by exploratory puncture of the pleura. 



314 PHYSICAL DIAGNOSIS 

■ « 

HYDROTHORAX 

Clinical Pathology. — The transudation of serous, noninflamma- 
tory fluid into the pleural cavity occurs most frequently in connec- 
tion with cardiac or renal disease, conditions which are not infre- 
quently attended by general anasarca. Hydrothorax of cardiac 
origin is more pronounced upon the right side, and, indeed, the 
fluid transudation is occasionally confined entirely to the right 
pleural cavity. The predilection of this type of the disease for 
the right pleura is commonly ascribed to pressure which is pre- 
sumably exerted upon the azygos veins by an enlarged heart. 

The hydrothorax of renal origin is bilateral and the transudation 
does not attain to the degree which is commonly observed in con- 
nection with regurgitant cardiac lesions. Unilateral hydrothorax 
is occasionally caused by compression of the large veins by medi- 
astinal tumor, aortic aneurysm, or pleural neoplasm. 

In hydrothorax the fluid is clear and of slightly yellowish hue, 
with a specific gravity of 1,010 to 1,013, and is devoid of fibrin. 
Upon standing a slight sediment of flat, desquamated endothelial 
cells is demonstrable microscopically. 

The pleura shows little alteration in uncomplicated cases of 
hydrothorax. In the presence of coincident pleurisy the mem- 
brane presents the characteristic changes of this disease, and the 
fluid contains a variable number of polynuclear leucocytes. Old 
pleural adhesions occasionally produce a condition of loculated or 
encysted hydrothorax. 

Physical Signs. — The physical signs of hydrothorax are essen- 
tially those of effusion into the pleural cavity, without, however, 
the initial pleural friction sound of pleurisy. Occasionally lim- 
ited entirely to the right pleural sac, the effusion is invariably 
greater upon the right side of the thorax. In cases of cardiac 
origin the murmurs of cardiac insufficiency are apt to be in evi- 
dence as well as definite changes in the cardiac outline ; while in 
cases which are dependent upon renal disease signs referable to 
the kidneys are usually present. In the absence of general an- 
asarca, moderate edema of the feet and ankles is frequently 
demonstrable in hydrothorax. 

Exploratory puncture reveals the presence and the character of 
the fluid. 



DISEASES OF THE PLEURA 315 

PNEUMOTHORAX (HYDRO-, HEMO-, OR PYO-PNEUMO- 

THORAX) 

Clinical Pathology. — The accumulation of air or gas in the pleu- 
ral cavity may result from trauma or may arise as a complication 
of pulmonary disease. Pneumothorax is not infrequently pro- 
duced by perforating wounds of the chest wall by missiles or the 
sharp extremity of a fractured rib ; and it may be similarly estab- 
lished by the rupture of empyema necessitatis. 

Diseases of the lung by creating a communication between the 
bronchial system and the pleural cavity occasionally result in 
pneumothorax, as, for example, following the rupture of a tuber- 
culous cavity which is situated immediately subjacent to the 
pleura. The development of the Bacillus aerogenes capsulatus 
in the pleural cavity causes primary pneumothorax. 

In pneumothorax the pleural cavity contains air or gas, which 
compresses the lung, which becomes shrunken and carnified. The 
pleural cavity may be closed, with no communication with the 
exterior, constituting a closed pneumothorax; or it may possess a 
communication with a bronchus or externally through the chest 
wall, constituting an open pneumothorax. Associated with the 
pneumothorax there is commonly a variable quantity of serous 
fluid, pus, or blood, constituting, respectively, hydro-, pyo-, or 
hemo-pneumothorax. 

The liver or spleen is apt to be displaced downward, and the 
heart is displaced toward the opposite side of the thorax. 

Physical Signs. — Inspection. — In pneumothorax the patient is 
usually dyspneic and the facial expression is anxious. The af- 
fected side of the thorax presents a variable degree of unilateral 
bulging, and the intercostal spaces are frequently obliterated. 
Expansion upon the side of the disease is nil, and is in striking 
contrast with the vicarious expansion of the opposite side of the 
thorax. The cardiac impulse is displaced laterally, toward the 
side of the sound lung. The patient as a rule prefers to lie upon 
the side of the pneumothorax in order to give the sound lung 
free play, though occasionally the dyspnea is so great that the up- 
right posture is assumed. The diaphragmatic shadow is abolished 
upon the side of the disease. 

Palpation. — Vocal fremitus is abolished over the pneumothorax, 
unless it is conducted to the surface of the thorax by pleural ad- 
hesions. The intercostal spaces offer increased resistance upon 
palpation with the finger-tips. 



316 PHYSICAL DIAGNOSIS 

Percussion. — The percussion findings are variable in pneumo- 
thorax, depending upon the degree of tension of the air in the 
pleural cavity and the amount of fluid which is present therewith. 
When the pleural cavity contains a considerable quantity of fluid, 
percussion of the dependent portion of the cavity yields flatness, 
changing abruptly to a tympanitic note when the upper border of 
the fluid is passed. The limit of pulmonary resonance is extended 
upward above the clavicle, and in the absence of fluid downward 
over the areas of hepatic and splenic dullness as well. The coin 
test of Gairdner is readily elicited in pneumothorax, and when 
fluid is present, movable dullness is demonstrable. 

Pneumothorax with patent bronchial communication frequently 
yields a cracked-pot sound upon forcible percussion, and occasion- 
ally Wintrich 's change of note may be elicited. Also in these cases 
Biermer's phenomenon, an alteration in the pitch of the percussion 
sound with change in the patient's posture, may be elicited. The 
area of dullness of the heart is frequently diminished, percussion 
over the precordia yielding hyperresonance or tympany as a result 
of cardiac displacement. - The dullness of the liver or the spleen is 
apt to extend to an abnormally low level. 

Auscultation. — As a rule, the respiratory murmur is absent over 
a pneumothorax, though in some cases distant amphoric breathing 
is audible. The voice sounds are ringing and amphoric. Over the 
opposite side the breathing is puerile from compensatory emphy- 
sema. The metallic tinkle is audible in many cases, as well as the 
succussion sound upon suddenly jarring the patient. In cases with 
patent bronchial fistula the lung-fistula sound is apt to be elicited. 
The heart tones frequently possess a hollow, echoing sound, due to 
the proximity of the air in the pleural cavity. 

Diagnosis. — The unilateral bulging, with suppressed or absent 
breath sounds, tympanitic percussion note, the falling-drop 
sound, and the succussion sound, with cardiac and visceral dis- 
placement, constitute a characteristic picture. 

The differential points between pneumothorax, pleural effusion, 
and hydrothorax, have been discussed in a previous section (see 
pp. 305, 306). 



SECTION IV 

PHYSICAL EXAMINATION OF THE CIECULATORY 

OEGANS 

CHAPTER XH 
CLINICAL ANATOMY 

THE HEART 

The heart, the great muscular pump by which the column of 
blood is propelled through the vessels, is a roughly conical organ, 
situated obliquely in the middle mediastinum between the lungs, 
whose anterior borders partially overlap its ventral surface. 
The heart presents for examination a base, which is directed up- 
ward and toward the right, an apex, which is directed downward 
and toward the left, and three borders; namely, right, left, and 
inferior. The heart does not occupy the midpoint of the thoracic 
cavity; but projects farther to the left of the median line than to 
the right. Approximately one-third of the organ lies in the right 
half of the thoracic cavity, and two-thirds to the left of the 
median line. 

The heart is a hollow muscular organ, comprising four cham- 
bers or cavities, an auricle and a ventricle upon either side, the 
cavities of the one side being separated from those of the opposite 
side by a muscular septum. Each auricle, on the contrary, com- 
municates with the corresponding ventricle through the auriculo- 
ventricular orifice. The left auricle and ventricle contain arterial 
blood, while the right auricle and ventricle contain venous blood. 

The external surface of the heart presents definite markings, in 
the form of transverse and longitudinal furrows, which accurately 
indicate the internal subdivisions of the organ. The auriculo- 
ventricular groove encircles the heart transversely at a point some- 
what nearer the base than the apex of the heart. This groove 
corresponds upon the surface of the heart to the site of the auriculo- 
ventricular septa, and lodges the coronary arteries. The inter- 
ventricular furrows pass downward from the auriculoventricular 
furrow in the direction of the long axis of the heart, upon its 

317 



318 PHYSICAL DIAGNOSIS 

■ ♦ 

anterior and posterior surfaces, respectively, terminating at the 
inferior sharp margin of the heart, which they reach a little dis- 
tance to the right of the apex. 

The cardiac wall is formed by bundles of specialized involuntary 
muscular fibers, the cardiac muscle, or myocardium, the bundles of 
which have a characteristic arrangement. The muscular bundles 
take origin from the fibrous rings which guard the auriculoven- 
tricular and aortic orifices. In the auricles the bundles are ar- 
ranged in two layers, a superficial and a deep lamina, the latter 
composed of looped and annular fibers. 

In the ventricles the bundles are likewise disposed in superficial 
and deep strata. The deep bundles encircle the ventricles, while 
the superficial fibers pursue a spiral course, coiling inward at the 
apex in the form of a whorl or vortex. 

The myocardium is not of uniform thickness. The auricular 
walls are much thinner than are those of the ventricles; and the 
right ventricle does not attain to the same thickness as does the 
corresponding ventricle of the opposite side. The cavities of the 
heart are lined by a serous membrane, the endocardium, which is 
reflected over the cusps of the cardiac valves. The external surface 
of the myocardium is clothed by a similar serous membrane, the 
epicardium, which constitutes a portion of the visceral layer of 
the pericardium. 

The right auricle consists of two portions : a principal cavity, the 
sinus venosus, or atrium; and an anterior recess, the auricidar 
appendix. The walls of the right auricle represent the thinnest 
portion of the myocardium, and they readily dilate when an in- 
creased load is thrown upon the right side of the heart by an 
obstacle to the circulation of the blood through the pulmonary 
circuit. The interauricular septum presents a depression upon the 
inner wall of the auricle, the fossa ovalis, corresponding to the 
foramen ovale of the fetus. In certain cases of congenital heart 
disease, and indeed in 14 per cent of adults, this foramen does not 
close completely, its patency often producing obscure physical 
signs. The capacity of the right auricle averages sixty cubic 
centimeters, slightly exceeding the capacity of the left auricle. The 
right auricle communicates with the right ventricle by the auriculo- 
ventricular orifice, which is guarded by the tricuspid valve; while 
it receives venous blood from the large superior and inferior venge 
cavae, the former returning blood from the head, neck, and upper 
extremities ; the latter returning blood to the heart from the trunk 
and lower extremities. 



CLINICAL ANATOMY OF CIRCULATORY ORGANS 319 

The left auricle, smaller tlian the right auricle, has thicker walls 
than the latter and hence its contractile power is greater. Like 
the right auricle, it is composed of an atrium and an auricular 
appendix. The left auricle communicates with the left ventricle 
by the bicuspid or mitral valve and it receives blood from the lungs 
through the large pulmonary veins. These large vessels usually 
empty their contents by four orifices in the base of the auricle ; but 
not infrequently these orifices are reduced to three, the two left 
pulmonary veins terminating in a common trunk. 

The right ventricle, triangular in contour, extends from the 
right auricle to the lower sharp border of the heart, reaching almost 
to the apex of the organ. Its anterior surface is convex and con- 
stitutes the major portion of the ventral aspect of the heart, the 
portion which is in relation to the anterior chest wall in the interval 
between the incisura cardiaca of the left lung and the left sternal 
border. The posterior surface of the ventricle is flattened and rests 
upon the central tendon of the diaphragm. The right ventricle 
has a capacity of about ninety cubic centimeters, and its walls 
are not as thick as are those of the left ventricle. The ventricu- 
lar wall is thinnest in the region of the superior and internal 
angle of the ventricle, the conns arteriosus, which overlies the 
opening of the pulmonary arterj^ In addition to the opening 
of the pulmonary artery, which is guarded by the semilunar valves, 
the ventricle communicates with the right auricle by the right 
auriculoventricular orifice, which is guarded by the tricuspid valve. 

The internal surface of the ventricle presents numerous muscular 
columns, columnce carnece, projecting from the myocardium and 
invested with endocardium. ■ Three, or it may prove to be four, of 
these muscular columns are very well developed and constitute the 
papillary muscles, which are connected with the margins of the 
cusps of the tricuspid valve by delicate tendinous cords, cJiordce 
ieyidinece. 

The left ventricle, longer, thicker, and more conical in shape 
than the right ventricle, forms only a limited portion of the ante- 
rior surface, but the major portion of the posterior surface of the 
heart. The inferior extremity of the left ventricle alone forms the 
apex of the heart. The capacity of the left ventricle varies from 
eighty to one hundred cubic centimeters, and its walls are thicker 
than any other portion of the myocardium. 

The interior of the left ventricle is similar anatomically to that 
of the right ventricle. The ventricular cavity communicates with 
the left auricle by the left auriculoventricular orifice, which is 



320 PHYSICAL DIAGNOSIS 

■ » 

guarded by the bicuspid or mitral valve ; and anteriorly and to the 
right of this valve it presents the aortic orifice, guarded by the 
semilunar valves. The right cusp of the mitral valve intervenes 
between the auriculoventricular and the aortic orifices; and, in 
the presence of aortic insufficiency, this cusp is apt to become the 
target of two streams of blood entering the left ventricle in opposite 
directions, the one from the left auricle and the other regurgitating 
from the aorta, and to be thrown into vibration with the production 
of a murmur, the murmur of Austin Flint, which will be described 
in a subsequent paragraph. 

THE CARDIAC VALVES 

The left auriculoventricular, bicuspid, or mitral valve, interven- 
ing between the left auricle and left ventricle, consists of a fibrous 
ring supporting two semilunar segments, or cusps. The concavity 
of each of these cusps is directed toward the ventricle ; and when, 
during ventricular systole their free margins are approximated, 
the auriculoventricular orifice is securely closed, and regurgitation 
of blood from the ventricle into the auricle is effectually prevented. 
Inversion of the valve segments during ventricular systole is pre- 
vented by traction upon their free borders by the papillary muscles 
through the medium of the chordge tendinese. 

The right auriculoventricular, or tricuspid valve, comprises three 
segments or cusps, supported at their bases by a fibrous ring. Their 
action is in all respects identical with that of the mitral valve, and 
their inversion during ventricular systole is similarly prevented by 
contractions of the papillary muscles with their chordae tendinese. 

The aortic valve consists of a fibrous ring supporting three semi- 
lunar cusps, with their concave surfaces directed toward the lumen 
of the aorta. This valve is devoid of chordae tendinese and papil- 
lary muscles ; but each segment is reinforced by a thin cartilaginous 
plate, the corpus arantii. The valve is closed by the force of the 
blood column which is ejected into the aorta during the systole 
of the left ventricle. Hence, the closure of this valve is diastolic, 
whereas that of the mitral and of the tricuspid valves is systolic 
in time. Opposite each segment of the aortic valve the wall of the 
aorta presents a small pouch or dilatation, the sinus of Valsalva, 
from two of which arise the coronary arteries, which nourish the 
myocardium. 

The pidmonary valve, which intervenes between the right ven- 
tricle and the pulmonary artery, is similar anatomically to the 
aortic valve and its closure is effected in the same manner. 



CLINICAL ANATOMY OF CIRCULATORY ORGANS 321 

The function of the cardiac valves is to maintain a constant 
flow of blood in one direction. Owing to the delicacy of their 
structure, they become ready targets for infectious material which 
may gain access to the blood stream. As a result of such infection, 
structural changes, resulting in permanent deformity of the cusps, 
are apt to ensue, thus destroying the integrity of one or more of the 
valves. Such changes are inevitably followed by the sequence of 
events described under the effects of chronic valvular disease. Or, 
in the absence of infection and structural alteration in the valve 
segments, in the presence of malnutrition or excessive physical 
strain the fibrous rings at the orifices may stretch, with the result 
that the normal segments can no longer close the abnormally large 
orifice. In certain instances congenital deformities of one or more 
of the cardiac valves are the cause of imbalance of the circulation. 

THE BUNDLE OF HIS 

The only continuous muscular connection between the auricles 
and ventricles is the auriculoventricular bundle of His, which 
originates in the sinoauricular node of Tawara beneath the epi- 
cardium between the superior vena cava and the right auricle. 
Passing downward in the interauricular septum to the auriculo- 
ventricular junction, the bundle crosses the junctional tissues at 
this point and continuing its course in the interventricular sep- 
tum, divides to form two principal branches, right and left, re- 
spectively. These two trunks pass downward on either side of 
the interventricular septum, splitting into smaller and smaller 
divisions as the cardiac apex is approached. Eventually the finer 
terminals of the bundle reach the papillary muscles, and beneath 
the endocardium are distributed generally to the entire ventricu- 
lar musculature. 

It is now generally conceded that the bundle of His transmits 
the impulse which results in systolic contraction from the auricles 
to the ventricles and that disease, affecting the integrity of these 
fibers, plays an important part in the production of auricular 
and ventricular fibrillation as well as Stokes-Adams' disease. 

THE PERICARDIUM 

The pericardium is a conical seromembranous sac situated 
between the lungs in the middle mediastinum, and enveloping 
the heart and the great vessels arising from its base. With its 
apex directed upward and its base moored to the central tendon 
of the diaphragm by areolar tissue, the pericardium lies behind 



322 PHYSICAL DIAGNOSIS 

the sternum and the costal cartillages of tlie third, fourth, fifth, 
sixth, and seventh ribs of the left side. Anteriorly the peri- 
cardium is separated from the chest wall in the greater portion 
of its extent by the anterior borders of the lungs; but a small 
portion of the sac is in direct relation with the thoracic wall in 
the interval between the left sternal border and the anterior 
border of the left lung in the fourth and fifth intercostal spaces. 
The posterior surface of the sac is in contact with the bronchi, 
the esophagus, and the thoracic aorta. 

In the presence of inflammatory affections of the structures with 
which the pericardium is in contact, adhesions are apt to form, 
causing displacement of the sac with its contents. Or, adhesions 
may form between the sac and the chest wall, resulting in re- 
traction of the surface of the thorax. 

The pericardium is composed of an outer fibrous coat, which 
is prolonged upward upon the great vessels which arise within 
the sac, finally to blend with the deep cervical fascia ; and of an 
internal serous coat, which is reflected on to the heart as the 
epicardium. This layer secretes a small amount of serous fluid, 
enabling the parietal and visceral layers of the pericardium to 
glide noiselessly over each other during the cardiac contractions. 
In the presence of inflammation of the membrane, however, the 
membranes become dry and covered with exudate, with the pro- 
duction of a to-and-fro friction sound, corresponding fairly 
closely with the cardiac systole and diastole. 

In pericarditis with effusion the fluid is prone to collect on 
either side of the heart and below it, causing a gradual elevation 
and a flnal obliteration of the visible cardiac impulse. The peri- 
cardium and heart are separated by the diaphragm from the left 
lobe of the liver, and upon the extreme left, corresponding to the 
position of the apex of the heart, from the stomach. Hence in peri- 
cardial effusions the fluid gravitates toward the left, as the dia- 
phragm yields more readily to pressure on this side than it does 
upon the right, where it is in relation to the left lobe of the liver. 

THE AORTA 

The aorta, the principal arterial trunk of the greater or general 
circulation, arises from the aortic orifice at the superior and poste- 
rior portion of the left ventricle near the center of the heart at 
the level of the third left costal cartilage. The course of the 
thoracic aorta roughly resembles a shepherd's crook; and the 



CLINICAL ANATOMY OF CIRCULATORY ORGANS 323 

vessel is divided into three portions, the ascending aorta, the 
aortic arch, and the descending; aorta. The ascending aorta, 
which is enveloped by the apical portion of the pericardium, is 
approximately one and one-eighth inches in diameter, presenting 
near its origin the sinuses of Valsalva. The ascending aorta is 
two inches long, and at the upper border of the second right 
costal cartilage becomes continuous with the arch of the aorta. 
The ascending aorta occupies a position one-fourth inch behind 
the posterior surface of the sternum, separated from this bone by 
the enveloping pericardium and the right pleural sac. Near its 
termination the ascending aorta presents a dilatation, the sinus 
maximus which renders the lumen of the vessel at this point fusi- 
form or oval. An aneurysm of the vessel at this point upon rupture 
discharges its blood directly into the pericardium with speedily 
fatal result. Prior to rupture an aneurysm of this portion of the 
aorta is prone to compress the right auricle, superior vena cava, or 
pulmonary artery, leading to embarrassment of the circulation 
and engorgement of the superficial veins of the neck. 

The aortic arch commences at the level of the upper border of 
the second right costal cartilage and arches upward, backward, and 
to the left behind the manubrium sterni and in front of the trachea 
just above its bifurcation. Thence the vessel crosses over the left 
bronchus and passes downward to the left side of the body of the 
fourth thoracic vertebra, where it becomes continuous with the 
descending thoracic aorta. In the superior mediastinum three 
large arterial trunks, the innominate, the left common carotid, and 
the left subclavian, spring from the convexity of the arch; while 
by its lower concave aspect it is connected with the pulmonary 
artery by a fibrous cord, the ligamentum arteriosum, the remnant 
of the obliterated ductus arteriosus of the fetus. 

Aneurysmal dilatation of the posterior wall of the aortic arch is 
apt to compress the trachea, producing cough, stridor, hemoptysis 
or fatal hemorrhage in the event of rupture. Pressure may also be 
exerted upon the esophagus with the production of dysphagia or 
upon the thoracic duct, resulting in lymph stasis or chylothorax. 
Similarly aneurysm of the anterior aspect of the arch may cause 
sternal protrusion with boring pain beneath the sternum. Through 
irritation of the left recurrent laryngeal nerve, which winds around 
this portion of the vessel, laryngeal symptoms may be induced, and 
through disturbance of the sympathetic nervous system pupillary 
changes may occur. 

The descending aorta, commencing at the left side of the lower 



324 PHYSICAL DIAGNOSIS 

border of the fourth thoracic vertebra, descends in the deep portion 
of the posterior mediastinum to the aortic orifice of the diaphragm, 
through which it passes in front of the body of the twelfth thoracic 
vertebra. Aneurj^sm of this portion of the aorta, which is not an 
uncommon disease, usually extends backward along the left side of 
the vertebral column, where it causes boring pain and absorption of 
the bodies of the vertebrae, resulting in scoliosis or lordosis. When 
developing upon the anterior Avail of the vessel, an aneurysm exerts 
pressure upon the pericardium and heart, pushing these structures 
before it, and giving rise to physical signs which suggest cardiac 
hypertrophy or pericarditis with effusion. In either situation rup- 
ture may occur into the mediastinum or pleural cavity with fatal 
termination. 

Congenital abnormalities of the aorta are not common, though 
occasionally the aortic valve may present an abnormality. This 
may consist of adhesions between the borders of the valve cusps, or 
fenestration of the segments ; or in rarer instances the orifice may 
be represented by a narrow slit, the button-hole orifice of Corrigan. 

THE PULMONARY ARTERY 

The pulmonary artery, springing from the base of the right 
ventricle at the conus arteriosus, lies anterior to all of the great 
vessels which are connected with the base of the heart. A short 
wide trunk, two inches in length and embraced by the right and 
left auricular appendages, the pulmonary artery passes upward 
and backward to reach the concavity of the aortic arch, where, in 
front of the bifurcation of the trachea, at the level of the fourth 
dorsal vertebra, it divides to form the right and left pulmonary 
arteries, which enter the roots of their respective lungs. 

Opening into the left auricle are the four pulmonary veins, which 
return arterial blood from the lungs to the left heart, while 
emptying into the right auricle are the superior vena cava, return- 
ing venous blood from the upper portion of the general circulation, 
and the inferior vena cava, returning venous blood from the ab- 
dominal cavity and lower extremities. 

TOPOGRAPHICAL ANATOMY 

The Heart. — The lase of the heart, formed by the right and left 
auricles, corresponds to a line crossing the sternum obliquely from 
the lower border of the second left costal cartilage at a point one- 
half inch to the left of its junction with the sternum to the upper 



CLINICAL ANATOMY OF CIRCULATORY ORGANS 325 

border of the third right costal cartilage at a point one inch beyond 
its sternal junction. 

The right 'border of the heart, formed by the right auricle, corre- 
sponds to a curved line, with its convexity directed toward the 
right, extending from the upper border of the third right costal 
cartilage one inch from its junction with the sternum, to the sixth 
ri2:ht chondrosternal articulation. 



Fig. 117. — Relation of chambers of unopened heart to anterior thoracic wall. LA, 
left auricle; LV, left ventricle; RA, right auricle; RV, right ventricle; P, pulmonic 
valve; A, aortic valve; 71/, mitral valve; T, tricuspid valve; AO, aorta; SVC, superior 
vena cava. 

The inferior border of the heart, formed almost entirely by the 
right ventricle, and to a minor extent by the left ventricle, corre- 
sponds to a line drawn from the sixth right chondrosternal articu- 
lation to the site of the normal cardiac impulse in the fifth left 
intercostal space one-half inch internal to the midclavicular line. 

The left border of the heart, formed by the left ventricle, is 
represented by a curved line drawn with its convexity directed 
upward and toward the left, from the fifth left intercostal space 
one-half inch internal to the midclavicular line to the lower border 
of the second left costal cartilage, one-half inch to the left of its 
articulation with the sternum. 



326 PHYSICAL DIAGNOSIS 

The cardiac valves all lie witliin a small* ellipse extending from 
the third left chondrosternal articulation to the junction of the 
sixth right costal cartilage with the sternum. Within this ellipti- 
cal area the pulmonary valve lies behind the third left chondro- 
sternal articulation at the level of the upper border of the third 
costal cartilage. The aortic valve occupies a position behind the 
sternum a little distance to the right of the pulmonary valve at the 
level of the third intercostal space. The mitral valve lies behind 
the left sternal border at the level of the fourth costal cartilage. 
The tricuspid valve occupies a position behind the body of the 
sternum corresponding to the central point of a line drawn 
obliquely across the midsternal line from the third left to the sixth 
right chondrosternal articulation. In relation to the anterior wall 
of the thorax, the pulmonary valve is most superficial ; the tricuspid 
is next in depth ; the aortic more deeply placed than the tricuspid ; 
while the mitral valve occupies the position most remote from the 
chest wall. This area overlies the anatomic site of the valves, and 
is not the area in which the sounds produced at the several valves 
are best appreciated acoustically. 

The Aorta. — The ascending portion of the aorta is represented 
on the surface of the thorax by a broad line drawn from the third 
left chondrosternal junction to the upper border of the second 
right costal cartilage at its junction with the sternum. From 
this point the arch of the aorta takes a course backward and to- 
ward the left behind the manubrium sterni, its convexity as- 
cending to a point one inch below the episternal notch, its con- 
cavity corresponding to the level of the angle of Louis. 

The pulmonary artery corresponds to a broad line drawn from 
the second left intercostal space to the upper border or the second 
left costal cartilage, the point of bifurcation of the artery to form 
its two primary branches. 

The Precordia. — The term precordia is applied to the area of 
the surface of the thorax which overlies the heart and peri- 
cardium. The name does not refer merely to the limited region 
in which the heart is directly in apposition with the thoracic 
wall, but also to the region in which the anterior borders of the 
lungs overlap the pericardium and heart. The region embraces 
the areas of cardiac dullness and cardiac flatness, to be described 
in a subsequent section. The precordia presents sharp lines of 
demarkation superiorly and upon the left; but upon the right 
side and inferiorly it is continuous with the areas of hepatic dull- 
ness and flatness. 



CHAPTER XIII 
INSPECTION 

Object and Technic. — Inspection is employed in the examina- 
tion of the circulatory organs for the purpose of detecting undue 
prominence or recession of the precordial region, the presence of 
abnormal pulsations within the limits of this region or along its 
lateral borders, to determine the site of the cardiac impulse, or 
apex beat of the heart, as well as the presence of capillary pulsa- 
tion in Corrigan's disease. 

During the examination of the precordia the patient should 
assume the sitting posture or the dorsal decubitus. The latter 
position is to be preferred in all cases in which it is not contra- 
indicated by subjective symptoms on the part of the patient. As 
subjects of myocardial and valvular disease of the heart fre- 
quently complain of urgent dyspnea and insupportable pain upon 
assuming the dorsal decubitus, it is necessary to make the exam- 
ination in the sitting or semi-sitting posture in many cases. 

In whatever attitude it may be necessary to examine the sub- 
ject, the thorax should be bare to the waist; and the illumination 
should fall equally and uniformly upon the two halves of the 
thorax. As in the case of inspection of the thorax in the presence 
of disease of the respiratory organs, daylight is the preferred 
source of illumination. 

During the course of the examination the student should pro- 
ceed methodically to the examination of the precordial region 
for undue prominence or recession ; for the presence of abnormal 
pulsations within or without the confines of this important area ; 
he should make a detailed study of the cardiac impulse, as to its 
site, displacement of the impulse from its normal site, its extent, 
and its force; and should take note of capillary pulsation in the 
extremities, if this sign is present. 

PRECORDIAL BULGING 

Bulging of the precordia develops as a result of intracardiac and 
extracardiac causes. As a general rule, undue prominence of the 
precordia which is referable to intracardiac lesions is restricted to 

327 



328 PHYSICAL DIAGNOSIS 

■ * 

the area along the left sternal border between the second and the 
seventh ribs ; bnt this is not an invariable rule, as in the presence of 
extensive pericardial effusion and cardiac aneurysm the bulging 
may be manifest beyond the right parasternal line. The degree 
of precordial bulging is influenced to a marked degree by the age 
and sex of the patient. The thin, plastic chest wall of childhood, 
as well as the thin chest wall of the spare female subject yields 
readily to intrathoracic pressure which is exerted in the pre- 
cordial region. 

Cardiac hypertrophy and dilatation, as well as pericarditis with 
effusion, results in rather conspicuous prominence of the pre- 
cordia. Aneurysm of the aortic arch produces bulging of the 
upper portion of the precordial space, the prominence in this in- 
stance extending well beyond the limits of the precordia. Pre- 
cordial bulging of extracardiac origin arises as the result of the 
continuous growth of a neoplasm of the mediastinal structures, 
lung, pleura, or chest wall; as a local manifestation of a localized 
pleural effusion or empyema necessitatis ; or as the result of caries 
of the sternum. 

PRECORDIAL RETRACTION 

Undue recession of the precordia is frequently the result of 
traction of pericardial or pleural adhesions. A not infrequent 
cause of retraction in this region is fibroid retraction of the 
anterior border of the left lung during the course of fibroid 
phthisis or chronic interstitial pneumonia. A similar recession 
constitutes the funnel-chest, whether as the result of occupation 
or occurring as a congenital defect. Precordial recession is oc- 
casionally encountered in which the underlying cause is extensive 
cavitation in the left lung in the course of chronic ulcerative 
phthisis. 

ABNORMAL AREAS OF PULSATION 

Pulsation within the limits of the precordia, in the regions 
immediately adjacent to this space, or less frequently in more 
remote regions possesses a varied significance, depending upon 
the localization and mode of production of the pulsation and its 
temporal relation to the events of the cardiac cycle. 

Pulsation at the Base. — A visible pulsation at the base of the 
heart, over the manubrium sterni, which is synchronous with ven- 
tricular systole, is indicative in the vast majority of cases of aneu- 



INSPECTION IN CARDIOVASCULAR DISEASE 329 

rysm of the transverse portion of the aortic arch. As a rule, when a 
visible pulsation is present in this region the aneurysm has eroded 
the bone, and is attended by pain of a dull, boring character. 
With less constancy pulsation at the base is referable to extreme 
cardiac hypertrophy or dilatation. 

Pulsation at the Right Sternal Border. — A visible pulsation 
along the right margin of the sternum, ranging from the second 
to the fifth interspace, points to aneurysm, cardiac enlargement, 
or displacement of the heart. The pulsation of aneurysm is situ- 
ated in the second interspace and corresponds to ventricular 
systole. A presystolic pulsation in the second, third, or fourth 
interspace is indicative of right auricular dilatation or of fibroid 
retraction of the anterior border of the right lung, v^hich nor- 
mally intervenes betw^een the right auricle and the anterior chest 
wall. Systolic pulsation along the right sternal border is most 
frequently indicative of cardiac displacement, the result of the 
traction of adhesions between the right pleura and pericardium, 
or developing as the result of the pressure of a left pleural effu- 
sion, pyopneumothorax, or subdiaphragmatic abscess. 

Pulsation at the Left Sternal Border. — Systolic pulsation along 
the left sternal border in the second and third interspaces, most 
prominent between the left sternal and left parasternal lines, ac- 
companies aneurysm of the aortic arch. Presystolic pulsation in 
the same area points to dilatation of the left auricle. In the pres- 
ence of fibroid retraction of the anterior border of the left lung, 
in the absence of definite vascular disease, arterial pulsation is oc- 
casionally visible adjacent to the upper portion of the left sternal 
border. Visible pulsation localized between the left sternal and 
midclavicular lines in the third, fourth, and fifth interspaces, not 
infrequently occurs as a consequence of cardiac displacement 
toward the left as the result of the pressure of air or fluid oc- 
cupying the right pleural cavity, or as the result of traction of 
adhesions which have formed between the left pleura and the 
pericardium. 

Sternal Pulsation. — Systolic pulsation in the upper sternal reg- 
ion is indicative of erosion of the sternum by aneurysmal dilata- 
tion of the aorta or, less frequently, of the innominate artery. 
The pulsation is accompanied by boring pain over the site of the 
erosin. 

Episternal Pulsation. — A systolic pulsation in the base of the 
neck, immediately above the episternal notch, accompanies aneur- 



330 PHYSICAL DIAGNOSIS 

ysm of the transverse portion of the aortic arch with great con- 
stancy. A similar pulsation of minor intensity occurs in this 
region when the subclavian artery is exposed by fibroid retraction 
of the lung. Visible pulsation in the episternal notch is frequently 
encountered in anemic states, after the ingestion of stimulants, 
and such pulsation is not infrequently a normal phenomenon in 
elderly subjects. 

Supraclavicular Pulsation. — Systolic pulsation in the right 
supraclavicular region is a constant sign of aneurysmal dilation 
of the innominate or subclavian artery, and the pulsation is usu- 
ally accompanied by a palpable thrill. Similarly, a systolic pul- 
sation in this region is a valuable sign of tricuspid regurgitation. 
In this instance, moreover, the pulsation may be abolished by 
exerting pressure over the lower portion of the jugular vein. In 
the presence of cardiac hypertrophy and in incompetence of the 
aortic valve there is frequently bilateral pulsation of the carotid 
region in the supraclavicular fossse. 

Hepatic Pulsation. — Systolic pulsation of the liver accompanies 
tricuspid regurgitation, and is usually attended by a variable 
degree of edema of the feet and ankles. Not infrequently a hepatic 
pulsation which is not visible is yet distinctly palpable upon 
bimanual palpation of the hepatic region. True expansile pulsa- 
tion of the liver, which occurs with incompetence of the tricuspid 
valve, must be differentiated from the impulse which is frequently 
transmitted to the liver by an overacting right ventricle. 

Epigastric Pulsation.— Systolic pulsation of the epigastrium 
is occasionally noted in the normal subject without possessing un- 
toward significance. Moreover, a systolic epigastric pulsation 
may accompany the condition of bathycardia, an abnormally low 
position of the heart in the thoracic cavity. Pathologic shortness 
of the sternum likewise causes a pulsation in the epigastrium, 
systolic in time. A systolic epigastric pulsation accompanies 
hypertrophy of the right ventricle, and occurs also when the 
heart is displaced to the right so that the apex lies behind the 
sternum. 

Diastolic pulsation of the epigastrium accompanies states of 
anemia and neurasthenia and is noted in patients with chronic 
gastric indigestion with great frequency. A diastolic pulsation 
in this region accompanies a tumor of an abdominal organ over- 
lying the aorta, the pulsation being transmitted to the tumor at 
each pulsation of the vessel. A similar pulsation accompanies 



INSPECTION IN CARDIOVASCULAR DISEASE 331 

aneurysm of the vessel. These pulsations are often not visible, 
but plainly palpable. 

Jugular Pulsation. — Systolic pulsation of the jugular veins, 
affecting particularly the right jugular, is an important sign of 
tricuspid regurgitation, a portion of the contents of the right 
ventricle during systole regurgitating into the corresponding auri- 
cle and producing a visible pulsation in the great vessels which 
empty their contents into the right side of the heart. A less frequent 
cause of systolic jugular pulsation is mitral regurgitation in the 
presence of an imperfectly closed foramen ovale, in which event 
the force of the regurgitation is exerted through this abnormal 
communication between the auricles upon the column of blood 
which is being discharged into the right auricle. True jugular 
pulsation is closely simulated by the communication to the vein 
of the impulse of the subjacent carotid artery. A communicated 
pulsation of this nature is identified by emptying the vein by 
stripping it upward with the fingers, in which event the vein 
does not refill from below. 

Turgescence of the jugulars is a prominent feature of venous 
compression by mediastinal tumor, adhesive mediastinitis, aneur- 
ysm, or enlargement of the mediastinal glands. Normally exhib- 
iting moderate distention during expiration, this respiratory 
overfullness attains to the degree of turgescence or engorgement 
during the dyspnea of bronchial asthma and hypertrophic em- 
physema. 

Jug*ular Collapse. — Diastolic collapse of the jugulars accom- 
panies chronic adhesive pericarditis, constituting Friedreich's 
sign of this disease. In chronic adhesive pericarditis the traction 
of mediastinopericardial adhesions produces retraction of the 
thoracic parietes during cardiac systole, the flexible walls of the 
thorax expanding during diastole, in this wise exerting an aspirat- 
ing action upon the contents of the great veins at the base of the 
right auricle, and by aspirating the blood from these vessels, 
causes diastolic collapse of the jugular veins. Unilateral jugular 
collapse, which does not disappear when the vein is compressed 
immediately above the clavicle, is indicative of lateral sinus 
thrombosis. 

„ Carotid Pulsation.— Pulsation over the distribution of the carot- 
ids accompanies cardiac hypertrophy and is a common sign of 
Corrigan's disease. "With less constancy carotid pulsation is 
noted in emaciated subjects without possessing untoward signifi- 
cance. 



332 PHYSICAL DIAGNOSIS 

THE VENOUS PUL§E 

The venous pulse, as recorded in the jugular veins, is encount- 
ered in either of two forms: (1) the negative venous pulse of 
health; and (2) the positive venous pulse of pathologic significance. 

Negative Venous Pulse. — The negative, auricular, or presystolic 
venous pulse is represented by a sequence of presystolic pulsa- 
tions, usually demonstrable in the external jugulars, and only 
rarely in the internal jugular veins. The negative venous pulse 
can only be demonstrated in the thin subject. In this type of 
venous pulse the presystolic pulse wave is initiated by the systole 
of the right auricle, w^hich, in addition to forcing the auricular 
contents onward through the right auriculoventricular valve, 
also causes coincidentally an impulse which is transmitted to the 
blood column in the superior vena cava and innominate veins, re- 
sulting in a presystolic impulse which is visible or palpable over 
the external jugular veins, particularly upon the right side of 
the neck. 

These veins, during late diastole or just prior to ventricular sys- 
tole, the time which corresponds to auricular systole, are filled, 
owing to the increased intraauricular tension ; whereas, during 
ventricular systole, corresponding to auricular diastole, the veins 
collapse, owing to lowering of the intraauricular tension, which 
promotes the unimpeded flow of blood from the veins. 

Sphygmograms from the external jugular vein of the negative 
venous pulse show often but a single wave, which corresponds to 
the auricular systole. But there may be two or even three waves, 
the second wave occurring during ventricular systole and cor- 
responding to the closure of the right auriculoventricular valve; 
the third wave occurring during ventricular diastole, and corre- 
sponding to the closure of the pulmonary valve. 

In determining the time of the negative venous pulse the ex- 
aminer should palpate the jugular vein with the finger-tips of 
the left hand, Avhile applying the tips of the fingers of the oppo- 
site hand to the opposite carotid artery or to the cardiac apex. 
This maneuver serves to distinguish the normal, negative venous 
pulse, which is presystolic, from a false venous pulse transmitted 
from the subjacent carotid artery, which is systolic in time. More- 
over, if digital compression is applied to the vein near the middle 
of the neck, after it has been emptied by pressure applied from 
below upward to the point of constriction, in the case of the nega- 
tive venous pulse the proximal portion of the vessel remains 
empty, while the distal portion, the portion beyond the point of 



INSPECTION IN CARDIOVASCULAR DISEASE 333 

compression, becomes overfilled and tortuous. Under these cir- 
cumstances in a false venous pulse the carotid pulsation is not 
transmitted to the lower, collapsed portion of the vein; but it is 
increased over the portion of the vein above the site of compres- 
sion. 

Positive Venous Pulse.- — The positive, ventricular, or systolic 
venous pulse is represented by a sequence of systolic pulsations 
of the internal jugular veins. This type of venous pulse is caused 
by direct regurgitation of blood into the right auricle from the 
ventricle during systole, as a result of incompetence of the tri- 
cuspid valve. Hence, it is a purely pathologic physical finding. 
Usually first demonstrable in the right jugular, owing to its 
closer proximity to the right auricle, the pulse eventually develops 
in the left jugular vein as well. In thoroughly competent jugular 
veins the impulse is interrupted at the suprabulbar valve. Under 
these circumstances the impulse is appreciable in the intersterno- 
mastoid fossa, just above the sternoclavicular articulation. But, 
as a rule, the valve above the bulb is not entirely competent and 
permits the impulse to be transmitted upward into the veins of 
the neck. 

While the provocative lesion of the positive venous pulse is in 
the great majority of cases tricuspid insufficiency, such a pulse 
is also produced in the rarer cases of mitral incompetence asso- 
ciated with patent foramen ovale. The positive venous pulse is 
usually accompanied by systolic pulsation of the liver. 

THE CENTRIPETAL VENOUS PULSE 

A visible pulsation, the centripetal or penetrating venous pulse, 
is occasionally visible in the veins of the dorsum of the mind or 
foot or in the delicate mammary veins. This pulse is most fre- 
quently associated with aortic insufficiency, and less commonly 
with anemic states in which it represents an exaggeration of the 
capillary pulse of Quincke. 

THORACIC RETRACTION (BROADBENT'S SIGN) 

In chronic adhesive pericarditis, with extensive adhesions be- 
tween the pericardium and the diaphragm, with each ventricular 
systole there is a systolic retraction of the thoracic wall. Broad- 
bent directed attention to the frequency with which systolic re- 
traction is visible upon the left side of the thorax posteriorly, be- 



334 PHYSICAL DIAGNOSIS 

■ * 

low the angle of the scapula in the tenth and eleventh inter- 
spaces in this disease. There is frequently a similar systolic re- 
traction of the anterior chest wall in the eighth and ninth inter- 
spaces in the left parasternal line. Aside from chronic adhesive 
pericarditis, localized systolic retraction in this area may ac- 
company excessive cardiac hypertrophy. 

THE CARDIAC IMPULSE (APEX BEAT) 

With each systole of the ventricles of the heart there ensues a 
circumscribed elevation of the thoracic wall which is superjacent 
to this portion of the organ, constituting the cardiac impulse, or 
apex beat of the heart. This impulse, which corresponds topo- 
graphically to the limited area of the chest wall which is in ap- 
position with the apex of the right ventricle, is in most instances 
distinctly visible ; and in the rarer cases in which it is not to be 
detected upon inspection, the impulse is readily detected and lo- 
calized by palpation. It is to be remarked, however, that in the 
case of deep chested subjects with voluminous lungs, as well as 
in the very obese subject, and in those cases in which the right 
ventricular apex occupies a position directly behind a rib, the 
impulse is occasionally neither visible nor palpable. 

In the normal adult subject the cardiac impulse is localized in 
the fifth left intercostal space one-half inch internal to the mid- 
clavicular line. While the impulse in the normal subject occupies 
this circumscribed area, yet it is important to bear in mind that 
its site is influenced by the age of the subject, by the structure of 
the thorax, by the movements of respiration, by changes in the 
attitude of the body, and by the presence of excessive physical 
exertion or emotional excitement. As displacements of the car- 
diac impulse from its normal site possess definite diagnostic sig- 
nificance, which varies with the direction of the cardiac displace- 
ment, it is important that the student be familiar with the dis- 
placements which may be caused by the factors enumerated above, 
and which are not to be considered pathologic. 

During infancy and early childhood, as a consequence of the 
relative shortness of the thoracic cavity and the relative increase 
in the vertical diameter of the abdominal cavity, the cardiac im- 
pulse not infrequently is encountered in the fourth intercostal 
space. Also, in this class of subject, owing to the relatively large 
heart which obtains at this time of life, it is not infrequent to en- 
counter the impulse external to the midclavicular line. In the 



INSPECTION IN CARDIOVASCULAR DISEASE 



335 



aged subject, on the contrary, partially as a result of hardening 
and straightening of the thoracic aorta, and partially as a result of 
falling of the abdominal viscera, the cardiac impulse commonly oc- 
cupies an abnormally low position in the thoracic cavity, being 
encountered in the sixth, or even in the seventh intercostal space. 
The structure of the thorax influences the normal site of the 
cardiac impulse in many instances. In subjects of unduly short 
thoraces, the impulse is not infrequently encountered in the fourth 
interspace ; whereas in cases in which the thorax is unduly 




Fig. 118-A. — Site of normal cardiac impulse. 



Fig. 118-B. — Site of normal cardiac impulse. 



elongated, it is not uncommon to find the impulse situated in the 
sixth intercostal space. Moreover, thoracic deformities due to 
scoliosis frequently produce displacements of the apex beat in 
the absence of cardiac disease. 

During deep, forcible inspiration the cardiac impulse is not in- 
frequently displaced to the extent of one interspace, to ascend to 
the fifth interspace during expiration. The excursions of the 
lungs, during tranquil respiration, on the contrary, produce no 
appreciable displacement of the cardiac impulse. In the presence 
of marked stenosis of the larger bronchi, it occasionally happens 
that during inspiration the diaphragm not only does not descend, 



336 PHYSICAL DIAGNOSIS 

but ascends into the thoracic cavity more' forcibly than is the case 
during normal expiration. In this event there is observed a re- 
versal of the ordinary train of events, with upward displacement 
of the apex beat during forcible inspiration. During deep in- 
spiration in the normal subject, the cardiac impulse, in addition 
to its depression, becomes more powerful and exhibits a slight 
increase in its extent, owing to its more intimate apposition w^ith 
the anterior thoracic wall. 

Following active physical effort, and frequently in the train 
of violent emotional excitement, the cardiac apex is increased in 
extent and assumes a position a little nearer the midclavicular 
line than is the case in the normal subject in repose. 

The attitude of the body exercises a powerful influence upon 
the site of the cardiac impulse as noted upon inspection with the 
subject in the various attitudes. When the patient assumes the 
left lateral decubitus the apex beat is displaced toward the left 
axillary line to the extent of one to two inches. Upon assuming 
the right lateral decubitus, owing to the natural lateral mobility 
of the heart, the apex beat shifts toward the sternal border, but 
the mobility of the organ in this direction never equals its mo- 
bility toward the left side of the thorax. In whatever site the car- 
diac impulse is detected, a correct localization of the area of im- 
pulse affords very accurate information as to the position of the 
heart within the thoracic cavity. 

The normal cardiac impulse covers an area of approximately 
one inch upon the surface of the thorax, being less extensive in 
the recumbent than in the sitting posture. In the area of the im- 
pulse there is an elevation of the chest wall corresponding to 
each ventricular systole, while around this area of protrusion 
there is a minor synchronous retraction of the soft structures, 
constituting the negative impulse of the heart. In the normal 
subject the elevation of the thoracic integument equals, but never 
exceeds the height of the adjacent regions of the thoracic surface. 

The cardiac impulse should be studied with a view to the de- 
tection of displacement from its usual site, of variations in its area 
or extent, and alterations in its force. 

DISPLACEMENT OF THE CARDIAC IMPULSE 

Aside from the physiologic displacements to which the cardiac 
impulse is subject, and which have been described in a previous 
paragraph, the apex beat is displaced as a result of pathologic 



INSPECTION IN CARDIOVASCULAR DISEASE 337 

changes in the niyocardmm, by the pressure or traction which is 
exerted upon the heart by the adjacent thoracic or abdominal 
viscera, and by extensive deformities of the thorax. The direc- 
tion and the degree of the apical displacement not infrequently 
yield a clue to the cause of the displacement. 

Upward displacement of the cardiac impulse is noted in the 
presence of cardiac atrophy; in the presence of diaphragmatic 
hernia ; and in the presence of elevation of the diaphragm by in- 
creased subphrenic pressure which occurs as the result of sub- 
phrenic abscess, ascites, tympanites, peritonitis, large abdominal 
tumor, or enlargement of the liver or spleen. In the presence of 
extensive retraction of the left lung as a sequence of fibroid 
phthisis, chronic interstitial pneumonia, or pulmonary syphilis, 
the impulse is elevated and is commonly visible over an exten- 
sive area along the left sternal border. In the presence of an exten- 
sive effusion into the right pleural sac, it occasionally happens 
that the liver is depressed, and rotates about its axis in such 
manner as to tilt the narrow left lobe of the organ upward, lead- 
ing to elevation of the superjacent heart and displacement of 
the cardiac impulse upward and toward the left. 

Downward displacement of the cardiac impulse occurs as a 
consequence of the progressive development of an aneurysm of 
the aortic arch, or of a mediastinal tumor which presses upon the 
base of the heart. A similar disiDlacement frequently attends 
hypertrophic emphysema as a result of pressure exerted upon the 
heart by the voluminous anterior borders and apices of the lungs 
in this disease. 

Extensive pericardial effusion, prior to the obliteration of the 
cardiac impulse, is frequently attended by downward displace- 
ment of the apex beat. In this instance, the cardiac muscle, hav- 
ing a greater specific weight than the liquid sinks downward ; and 
to this factor is added the weight of the effusion superimposed 
upon the superior diaphragmatic surface, which causes depres- 
sion of the diaphragm and left lobe of the liver. 

In addition to these extra-cardiac pulsion and traction dis- 
placements, the impulse is displaced downward and toward the 
left in left ventricular hypertrophy and dilatation, the impulse 
under these circumstances not infrequently occupying the seventh 
or eighth interspace in the anterior axillary line. 

Displacement to the Left.— In addition to the left lateral dis- 
placement of the cardiac impulse which occurs in left ventricular 
hypertrophy and dilatation, a further important cause of such 



PHYSICAL DIAGNOSIS 




Fig. 119. — Illustrating moderate displacement of the heart toward the left in compensa- 
tory emphysema of the right lung, with elevation of the left vault of the diaphragm 
and displacement toward the left of the structures in the median line of the neck. 




Fig. 120. — ^Illustrating cardiac displacement toward the right in compensatory emphy- 
sema of the left lung, which is attended by depression of the diaphragm upon the left 
side and by displacement of the structures of the median line of the neck toward the 
right side. 



INSPECTION IN CARDIOVASCULAR DISEASE 339 

displacement is right ventricular dilatation, in which the apex- 
beat is frequently localized external to the left midclavicular 
line. Horizontal displacement of the impulse to the left occurs as 
a consequence of the pressure exerted by the progressive ac- 
cumulation of fluid or gas in the right pleural cavity, and as a 
result of the traction of adhesions between the pericardium and 
left lung. Fibroid retraction of the left lung leads to left lateral 
displacement and elevation of the impulse, as does also hepatic 
enlargement or gastric distention. Similar displacement of the 
apex-beat attends pericardial effusion of moderate degree. 

Displacement to the Right. — The cardiac impulse is displaced 
toward the right by the pressure of fluid or gas in the left pleural 
cavity, and is drawn to that side by the traction of right pleuro- 
pericardial adhesions. Compensatory emphysema of the left 
lung when marked may push the impulse to the right. In right 
ventricular hypertrophy and dilatation the impulse is displaced 
toward the right, perhaps lying behind the sternum. A similar 
displacement is noted in the rare cases of congenital transposition 
of the thoracic viscera. 

VARIATIONS IN THE AREA OF THE CARDIAC IMPULSE 

Normally occupying an area of approximately one inch upon 
the surface of the thorax, the cardiac impulse in disease presents 
marked variations in the extent of the visible pulsation. Under 
these circumstances the impulse may occupy an abnormally ex- 
tensive area ; it may be decreased in extent ; or it may be totally 
absent. 

Increased Extent. — The area of the cardiac impulse is increased 
in emotional states and following great physical exertion or ex- 
citement, without possessing untoward significance. The extent 
of the impulse is increased in the cardiac overaction accompanying 
acute fevers or disorders of cardiac innervation. The area of 
impulse is increased by a mediastinal tumor pushing the heart 
forward, as also in cardiac hypertrophy and dilatation, in which 
latter it is observed over a very wide area. An increased area of 
cardiac impulse occurs when fibrosis of the anterior border of the 
left lung exposes an increased extent of the cardiac wall to the thor- 
acic parietes, and when the left lung is drawn aside by pleural ad- 
hesions. 

Decreased Extent. — In hypertrophic emphysema, owing to the 
crowding of the anterior borders of the lungs between the heart 



340 PHYSICAL DIAGNOSIS 

■ » 

and cliest wall, the area of impulse of the heart is decreased, and 
occasionally is entirely abolished. In the extreme grades of car- 
diac dilatation, instead of occupying an abnormally wide area 
upon the surface of the thorax, the cardiac impulse is decreased 
in area or is invisible. Moreover, in deep-chested subjects there 
is apt to be a very slight impulse, and it is not infrequently en- 
tirely absent. An absence of the impulse may in some instances 
be explained by the fact that the apex is situated directly behind 
a rib. 

VARIATIONS IN THE FORCE OF THE CARDIAC IMPULSE 

As the cardiac impulse in the presence of disease of the heart 
and adjacent thoracic viscera presents variations in its area of 
impulse, so also under somewhat similar circumstances the force 
of the impulse is altered, with or without possessing untoward 
significance. 

Increased Force. — In cardiac hypertrophy, in addition to being 
more diffuse than normally, the cardiac impulse possesses undue 
force. Displacements of the impulse are constantly found with 
major grades of hypertrophy. During active physical exertion 
and during strong emotional excitement there is a temporary in- 
crease in the force of the impulse. Following the ingestion of 
stimulants, during the course of acute fevers, and during acute 
myocarditis, the impulse is abnormally strong. 

Decreased Force. — Diminution in the force of the cardiac im- 
pulse occurs when cardiac dilatation supervenes upon hyper- 
trophy, as well as in conditions of fatty change in the myocardium 
and in cardiac atrophy. In the presence of edema and inflamma- 
tion of the chest wall the strength of the cardiac impulse is dimin- 
ished, and in pericardial effusion or hypertrophic emphysema it 
is weakened or is entirely obliterated. In pericarditis with ef- 
fusion the impulse occasionally becomes visible when the patient 
bends forward, to disappear when the erect posture is resumed. 

DOUBLE IMPULSE 

Occasionally the area of the cardiac impulse presents two dis- 
tinct pulsations to a single arterial pulse as recorded in the carot- 
ids. This discrepancy in the cardiac and arterial impulses may 
be due to the fact that the two ventricles contract asynchron- 
ously, or to the fact that ventricular systole occurs with variable 



INSPECTION IN CARDIOVASCULAR DISEASE 



341 



intensity, not every ventricular systole possessing sufficient force 
to produce an arterial pulse. 

SYSTOLIC RECESSION 

During the forcible contraction of an excessively hypertrophied 
heart, and with less constancy in the presence of cardiac dilata- 
tion, there is a systolic recession about the area of the cardiac 
impulse, as the result of the action of atmospheric pressure. Such 
systolic recession is not to be confused with the normal negative 
impulse or Avith the more extensive traction recession of chronic 
adhesive pericarditis. 




Fig. 121. — Demonstration of capillary pulse. 



CAPILLARY PULSATION (THE CAPILLARY PULSE) 

Systolic pulsation in the capillaries is sometimes a normal 
phenomenon; it may be the result of temporary loss of vasomotor 
tone during anemia or febrile diseases; but it is a very valuable 
sign of aortic insufficiency or Corrigan's disease. 



342 PHYSICAL DIAGNOSIS 

There are several methods of demonstrating capillary pulsa- 
tion. A serviceable method is by blanching the finger nail by the 
exertion of slight pressure upon the tip of the nail, whereupon a 
systolic flushing and a diastolic blanching of the subungual tissues 
will be observed, the capillary pulse. Another method of demon- 
strating the phenomenon is by drawing the nail over the fore- 
head, producing a line, which is alternately red and blanched. 
A third method of detecting capillary pulsation is by covering 
the lower lip by a glass slide and observing the systolic flushing 
and diastolic blanching of the lip which is compressed by the slide. 
The capillary pulse is frequently accompanied by visible pulsa- 
tion in the veins of the dorsum of the hand or foot, the centripetal 
venous pulse. 



CHAPTER XIV 

PALPATION 

In the study of cardiovascular disease palpation is employed in 
the localization of the cardiac impulse when it is not visible upon 
inspection. In palpation of the apex-beat information is gained 
as to increase or decrease in the area of the impulse, exaggera- 
tion or enfeeblement of its force, its quality, whether slow and 
heaving as in cardiac hypertrophy, or quick and slapping as in 
cardiac dilatation; or whether the apex-beat is regular or irregu- 
lar. Shock from closure of the cardiac valves may be appreciated 
and, finally, friction fremitus and thrills may be detected by pal- 
pation of the precordia. Palpation is also employed in the study 
of the radial pulse. Palpation also serves to confirm the findings 
of inspection as to prominence or retraction of the precordia, and 
pulsation within or without the precordia. 

VALVE SHOCK 

Valve shock is due to closure of the valves of the heart, and 
can be appreciated when the palm of the hand is applied flatly 
over the valve area in question. It may be felt over the auriculo- 
ventricular valves, but more distinctly over the semilunar valves 
in the aortic or the pulmonic area. In both instances it is more 
intense in persons with thin chest walls. In the aortic and pul- 
monic areas valve shock is accentuated in the presence of cardiac 
hypertrophy. 

The pulmonic shock is intensified by left-sided valvular lesions 
and in the presence of obstruction to the pulmonary circulation, 
such as occurs in emphysema and cirrhosis of the lung, conditions 
which raise blood pressure in the pulmonary circulation. 

The aortic shock is intensified in arteriosclerosis, chronic in- 
terstitial nephritis, and other conditions which are associated with 
increased blood pressure in the greater circulation. 

The shock of the auriculoventricular valves is systolic; that 
of the semilunar valves is diastolic. 

343 



d44 PHYSICAL DIAGNOSIS 

PERICARDIAL FRICTION i'*REMITUS 

Friction fremitus of pericardial origin is appreciable as a tactile 
vibration, which is generated by the apposition of the surfaces of the 
parietal and visceral layers of the pericardium, which have become 
roughened by inflammation in the development and evolution of 
acute fibrinous pericarditis or in the early stage of serofibrinous 
pericarditis. The fremitus in the latter disease is prone to dis- 
appear with the gradual accumulation of the effusion, which 
separates the layers of the pericardium, though it is not uncom- 
mon for the fremitus to persist at the base of the heart. 

Pericardial friction fremitus does not extend beyond the pre- 
cordia, and it is frequently attended by moderate pain, which is 
aggravated by pressure over the lower portion of the sternum. 

THRILLS 

Upon light palpation of the precordia of a patient who is the 
subject of valvular disease of the heart, aneurysm, or anemia in 
certain instances, a local palpable vibration of the chest wall is 
apt to be noted at one or more points, which is not dissimilar to 
the sensation which is conveyed to the hand when it is placed 
upon the throat of a purring cat, fremissement cataire. This vi- 
bration is termed a thrill. 

Thrills are cardiac, vascular, or hemic in origin; and in their 
clinical manifestations they are presystolic, systolic, or diastolic. 
A cardiac thrill is generated by the same mechanism which is 
responsible for the production of an endocardial murmur ; namely 
a narrowing of an orifice through which the blood stream is pro- 
jected into a larger chamber beyond. So long as normal blood 
flow\s through normal vessels and orifices of normal caliber, no 
tactile vibration is generated; but when the lumen at one point 
is diminished, the blood passing through this orifice into the 
wider distal portion is thrown into whorls, the so-called "fluid 
veins," the vibrations of which are conveyed to the precordia as 
a tactile vibration or thrill, which is the palpatory equivalent of 
a murmur. 

As thrills of cardiac origin are confined to limited areas of the 
precordia, they are most surely detected in the first instance by 
light palpation with the palm of the hand, after which they may 
be more definitely defined by finger-tip palpation. Firm pressure 
with the palm frequently serves to obliterate a thrill. The in- 
tensity of a thrill is very variable, often disappearing in the 



PALPATION IN CARDIOVASCULAR DISEASE 



345 



case of a feebly acting heart, to reappear with, improvement in 
the state of the myocardium. The quality of a thrill varies v^ith 
the rate of the vibrations, rapid vibrations of the blood stream 
producing fine thrills and murmurs of high pitch, whereas less 
rapid vibrations result in coarse thrills and murmurs of lower 
pitch. 

In general, a systolic thrill at the base of the heart is indica- 
tive of aortic aneurysm, exophthalmic goiter, or valvular disease 
of the aortic or pulmonary valves. The thrill of aortic aneurysm 
is commonly localized in the second and third interspaces to the 





122-A. — Sites of palpable thrills and 
pericardial friction fremitus. 



Fig. 122-B. — Sites of palpable thrills and 
pericardial friction fremitus. 



right of the sternum; that of aortic stenosis in the second right 
intercostal space at the right of the sternal border, while the 
thrills of pulmonary stenosis and of exophthalmic goiter are pal- 
pable in the left second interspace adjacent to the left sternal 
border. Diastolic thrills at the aortic and pulmonary areas oc- 
casionally accompany regurgitant lesions of the aortic and pul- 
monary valves; but thrills are present with greater constancy in 
the presence of stenotic than of regurgitant lesions. 

A presystolic thrill localized over the cardiac apex in the fifth 
left intercostal space is a very good sign of mitral stenosis. How^- 



346 PHYSICAL DIAGNOSIS 

ever, a similar thrill often accompanies *tlie Flint murmur of 
aortic regurgitation. Occasionally mitral regurgitation is at- 
tended by a systolic thrill in the apical area. 

A presystolic thrill palpable in the tricuspid area over the 
lower portion of the sternum frequently is present with the in- 
frequently encountered tricuspid stenosis. A systolic thrill in 
this area is occasionally detected in tricuspid regurgitation. 

THE CARDIAC IMPULSE 

In palpation of the cardiac impulse the palm of the hand should 
in the first instance be applied firmly over the site of the impulse 
and its force should be noted. Then the more sensitive finger- 
tips are applied in the same area in order to more definitely local- 
ize the position of the impulse and by separating the fingers the 
area of the impulse is readily estimated. 

THE PULSE 

By the term pulse is understood an expansion and subsequent 
retraction of an artery following each systole of the ventricle. 
Usually the radial artery at the wrist is the site selected for study- 
ing the pulse on account of its readiness of access ; but other arteries, 
as the temporal, carotid, or femoral will serve the purpose. The 
pulse may be studied by digital examination, or by means of the 
sphygmograph. 

TECHNIC OF TAKING THE PULSE 

In studying the pulse the patient should be in the sitting or 
recumbent posture with the arm extended and resting upon a 
table or supported by the left hand of the examiner. The examiner, 
seated beside the patient, should place the finger-tips over the 
radial artery, the index finger being nearest to the patient's hand. 
With the fingers in this position the examiner may roll the artery 
beneath them and can study the several factors which enter into 
the analysis of the pulse. 

It is well in conditions where there is no cause for hurry to count 
the pulse for a full minute, as observed by the second hand of a 
watch. However, the pulse may be counted for twenty seconds 
and the result multiplied by three; or it may be counted for thirty 
seconds and the result multiplied by two. 



PALPATION IN CARDIOVASCULAR DISEASE 



347 



In certain diseases the pulse becomes so rapid that it is im- 
possible to count all of the individual beats. Under such circum- 
stances an approximate estimate of the frequency of the pulse 




Fig. 123. — Palpation of cardiac impulse (first maneuver). 




Fig 124. — Palpation of cardiac impulse (second maneuver). 



348 



PHYSICAL DIAGNOSIS 



may be made by endeavoring to count every other beat, or the 
examiner may make dots with a pencil held in the unengaged 
hand and count the number of dots which are made during a 
minute. 

In certain conditions in which the radial pulse cannot be pal- 




Fig. 125. — Palpation of cardiac impulse (third maneuver). 




i''ig. 126. — Palpation of the radial pulse. 



PALPATION IN CARDIOVASCULAR DISEASE 349 

pated, as well as in cases in which it is suspected that every 
systole of the ventricle does not produce a radial pulsation, the 
examiner may arrive at a conclusion by auscultating the apical 
area and counting the systoles simultaneously with the taking of 
the pulse. 

THE SPHYGMOGRAPHIC TRACING 

A tracing of the normal pulse, or sphygmogram, shows that the 
pulse wave consists of a sudden upstroke, the anacrotic limb, 
and of a gradual decline, the catacrotic limb. The latter falls 
gradually to the base line and is interrupted by a distinct notch 
midway in its descent, the dicrotic notch, Avhich is followed by an 
immediate second ascent to a variable extent, the dicrotic wave, 




Fig. 127. — Normal sphygmogram. A, Anacrotic limb; B, dicrotic notch; C, dicrotic wave; 
D, postdicrotic wave; E, catacrotic limb. 

which is again followed by a second wave, the postdicrotic wave, 
upon the descent to the base line. 

The significance of the two principal strokes of the tracing is 
understood, the anacrotic limb being produced by the injection of 
blood into the already distended arteries by the ventricular 
systole, and the catacrotic limb being produced by the recoil of 
the elastic arterial walls to their normal caliber. 

The cause of the dicrotic wave is uncertain. It occurs im- 
mediately following the closure of the aortic valves ; and it oc- 
curs in all pulse tracings, varying, however, in degree. In cer- 
tain diseases, as in the early stage of typhoid fever, it is so 
pronounced and so constant as to lead to the designation ''di- 
crotic pulse." The accepted explanation is that the dicrotic wave 
is due to the rebound of the distended aorta at the time of the 
closure of the semilunar valves. 



350 PHYSICAL DIAGNOSIS 

■ * 

The second notch, on the catacrotic limb and the undulatory 
oscillations of the fall to the base line are in all probability due 
to inertia of the instrument. 

VARIATIONS IN THE SPHYGMOGRAM 

The most frequent pathologic variations in the sphygmogram 
are due to increase and decrease in the arterial tension, respec- 
tively. In states of high arterial tension attending arteriosclerosis 
and chronic nephritis, after the anacrotic limb attains the maxi- 
mum height, instead of receding promptly as in conditions of 
normal arterial tension, the stroke is sustained for a variable 
time, producing a "plateau," and then gradually falling to the 
base line. 

In states of low arterial tension, on the contrary, occurring as 
a result of temporary vasomotor relaxation or after profuse 
hemorrhage, the tracing presents a vertical anacrotic limb, which 
is immediately followed by a quick fall to the base line, with a 
rather marked dicrotic wave. 

CHANGES IN THE ARTERY 

When the radial artery is palpated with the finger-tips it is 
observed that at each pulse wave the artery is changed from a flat 
tube into a circular one, and moreover, that the vessel lengthens 
or straightens out during this period. 

ANALYSIS OF THE PULSE 

In analyzing the pulse the examiner should study the points 
enumerated below, variations in one or all of which possess defi- 
nite diagnostic significance. 

1. The condition of the arterial wall. 

2. The size of the artery. 

3. Rate. 

4. Ehythm. 

5. Tension. 

6. Volume. 

7. Force. 

8. Duration. 

9. Bilateral symmetry of the pulses. 

The Condition of the Arterial Wall. — The wall of the normal 
radial artery in a person who is not advanced in years is soft and 



PALPATION IN CARDIOVASCULAR DISEASE 351 

yielding, is readily compressible, and cannot be distinguished in 
consistence from the surrounding tissues. Any departure from 
the normal elastic state of the artery is abnormal and of potent 
diagnostic significance. In the aged subject and in the presence 
of arteriosclerosis due to alcoholism, syphilis, gout, or other 
cause, the artery becomes hard and its walls unyielding. The 
vessel often may be rolled betAveen the fingers and the lower end 
of the radius and it feels like a pipe stem. Or, on the other 
hand, the artery may be beaded and tortuous, with palpable 
nodules along its course, which are due to plaques of atheromatous 
degeneration of the arterial Avail. In subjects past middle age 
and in the earlier stages of arteriosclerosis, however, the artery 
may be merely palpably stiff and less readily compressible than 
the normal vessel. 

The Size of the Artery. — Variations in the size of the radial 
artery only occasionally possess diagnostic significance. The ar- 
tery may be congenitally larger or smaller than normal. How- 
ever, variations in the size of the artery are also produced by the 
amount of blood Avhich is expelled at each systole of the left 
ventricle. In ventricular hypertrophy with competent valves 
this amount is increased Avith consequent increase in the size of 
the elastic artery, whereas in the presence of incompetence at 
the aortic valve and in extreme cardiac asthenia the antithesis 
of this condition obtains. 

The Rate of the Pulse. — The normal pulse rate in the adult 
male subject varies from 70 to 75 beats per minute. The rate 
however, is modified by many factors, as the age, sex, the size 
.of the body, the position which is assumed by the patient, and 
the relations of the time of taking the pulse to the ingestion of 
food. At birth the pulse rate is 130 to 140 beats per minute ; dur- 
ing the first year of life it is 115 to 130; at the seventh year it 
averages 85 to 90; while in the aged subject it drops to 60 to 70 
beats per minute. In women the pulse is usually more rapid than 
it is in the male subject. 

The size of the body has a slight influence upon the pulse rate, 
the rate being lower in large subjects than it is in persons of small 
stature. The position of the patient influences the pulse rate, the 
pulse being constantly more rapid when counted in the upright 
posture than when taken Avhile the patient is recumbent. The 
pulse rate is likeAvise quickened for an hour or two following a 
full meal. Exercise and mental or emotional excitement serve 
to cause a temporary increase in the pulse rate, not infrequently 



352 PHYSICAL DIAGNOSIS 

doubling the normal rate for the individual. Finally, the ex- 
aminer should remember that the ingestion of many drugs in- 
fluences the rate of the pulse and proper inquiry should be di- 
rected toward this point. 

Physiologically the rate of the pulse is influenced largely by 
the degree of peripheral resistance which is offered to the on- 
ward course of the blood stream. If the peripheral resistance is 
high, the heart contracts compensatorily more slowly and power- 
fully; whereas if the peripheral resistance be diminished by re- 
laxation of the arterioles, the heart contracts more rapidly. The 
rate of contraction is also influenced by the cardiac innervation, 
stimulation of the vagus nerves slowing the heart and pulse rate, 
while depression of these nerves or reflex stimulation of the 
sympathetic innervation causes a corresponding increase in the 
heart and pulse rate. 

An abnormally slow pulse rate corresponds to bradycardia, 
whereas an abnormal acceleration of the pulse rate attends 
tachycardia, whether it be essential, reflex, or paroxysmal. Brady- 
cardia occurs during convalescence from typhoid fever, pneu- 
monia, and many acute infectious fevers, as a result of temporary 
exhaustion of the patient. In increased intracranial tension from 
cerebral tumor, abscess, or hemorrhage, and after injuries to the 
cervical portion of the spinal cord, and in all lesions producing 
continuous irritation of the vagus centers, the pulse rate is ab- 
normally slow. The pulse rate is also decreased in the presence 
of aortic stenosis, as Avell as in sclerosis of the coronary arteries, 
general arteriosclerosis, and fibrous myocarditis, the latter three 
conditions frequently coexisting in the same subject. 

Acceleration of the pulse rate occurs during fevers and as a 
result of vagus neuritis, the toxemia of exophthalmic goiter, as a 
result of excessive physical exertion or emotional excitement, as 
well as during failing compensation in valvular disease of the 
heart. 

Rhythm.— In health the pulse beats are of equal force and the 
beats are separated by uniform intervals. It follows that an 
irregularity of the pulse may have reference either to the force or 
the time sequence of the beats. 

Arrhythmia is a deviation from the normal sequence of the 
beats without the omission of beats. It is observed during the 
course of acute fevers, in the presence of valvular lesions of the 
heart, particularly in mitral stenosis, during digestive disturb- 
ances, following the excessive indulgence in tobacco, in lesions 



PALPATION IN CARDIOVASCULAR DISEASE 353 

of the brain, in gont, and in the presence of myocardial degenera- 
tion, in which indeed it may be the only sign. Arrhythmia is 
not infrequently noted in elderly subjects without possessing un- 
toward significance. 

Intermission is the occasional omission of a pulse beat. The 
omission may occur at irregular intervals or the omission may fol- 




Fig. 128. — Sphygmograms of pathologic types of pulse. A, Pulsus magnus; B, pulsus 
parvus; C, pulsus celer; D, pulsus tardus. 

low a regular sequence, every third or every fourth beat being 
omitted. Intermission may persist throughout life without possess- 
ing untoward significance; or it may be merely a transient phe- 
nomenon. It is usually attributable to nervous depression or to the 
excessive use of stimulants or of tobacco. 

In the analysis of a case of intermission it is important to deter- 
mine whether the omission of the pulse beat is due to an omission 



354 PHYSICAL DIAGNOSIS 

of ventricular systole, the pulsus deficie7vsy or whether due to a 
ventricular contraction which is too feeble to produce a radial 
pulse, the pulsus intermittens. 

"When omissions of pulse beats follow a regular sequence, when 
they are rhythmically irregular, it is termed an allorrhytJimic 
pulse. In this variety of intermission belong the pulsus higeminus, 
where two beats occur in regular sequence and are followed by an 
omission; and the pulsus trigemifiuSf in which three beats occur 
regularly to be followed by an omission of the pulse. A very fre- 
quent form of irregularity is represented by the pulsus intercidens, 
a pulse in which after several regular beats the last regular beat is 
quickly succeeded by a feeble pulse wave. 

The paradoxical pulse is a pulse in which toward the completion 
of inspiration the beats become small and more rapid, and may 
become imperceptible at the wrist. It occurs in pericarditis with 
effusion and in chronic adhesive pericarditis. 

Irregularities in the force of the successive pulse beats are due 
to ventricular systoles which are not of uniform force. This con- 
dition is noted in the pidsus alternans, a pulse of regular rhythm 
but in which the successive beats are irregular in force. 

Volume. — The volume or size of the pulse is dependent upon 
the amount of blood which is expelled during ventricular systole, 
upon the ability of the aortic valve to prevent regurgitation, and 
upon the state of the vasomotor nervous system. Thus, cardiac 
hypertrophy combined with vasomotor depression is attended by 
relaxation of the arteries which receive at each ventricular sys- 
tole an undue quantity of blood, with the consequent production 
of the full, bounding pidsus magnus. On the other hand, in left 
ventricular dilatation, combined with vasoconstriction, the pulse is 
small and thready, the pidsus parvus. This pulse is observed, in 
states of inanition, in mitral stenosis and regurgitation, and in 
extreme aortic stenosis, conditions in which the left ventricle cannot 
eject an adequate amount of blood into the aorta during systole. 

Force. — The force of the pulse depends upon the energy with 
which the left ventricle contracts, and upon the elasticity of the 
arterial walls. If the ventricle is hy]3ertrophied but the arterial 
walls have lost their elasticity, much of the heart's force in ex- 
pelling the blood is wasted or lost by the absence of the elastic 
recoil of the arteries. In general, the force of the pulse is in- 
creased in conditions of cardiac hypertrophy and is decreased in 
cardiac asthenia and dilatation. Moderate stimulation of the 
vagus nerves increases the pulse force by slowing the heart and 



PALPATION IN CARDIOVASCULAR DISEASE 



355 



increasing its period of repose; but if the stimulation is extreme, 
the ventricular contractions are so few that the decreased blood con- 




Fig. 129. — Sphygmograms of pathologic types of pulse. A, Pulsus frequens; B, pulsus 
rarus; C, pulsus bigeminus; D, pulsus trigeminus: E, pulsus durus; F, pulsus mollis; G, 
pulsus dicroticus. 



356 PHYSICAL DIAGNOSIS 

tent of the arterial system is not sufficient for the powerful 
ventricular systole to act upon and the force of the pulse is con- 
sequently diminished. 

Tension. — The tension of the pulse depends upon the energy of 
the ventricular contractions and the degree of peripheral re- 
sistance which is offered to the onward flow of the blood stream. 
With a powerfully contracting ventricle and the peripheral re- 
sistance increased by angiospasm or arteriosclerosis, the arterial 
tension is increased (hypertension). Hypertension accompanies 
all conditions of cardiac hypertrophy, arteriosclerosis, chronic 
interstitial nephritis, uremia, and cerebral hemorrhage. On the 
contrary, when the output of blood from the ventricle is decreased 
by cardiac dilatation or valvular disease, combined with vaso- 
motor relaxation, or a diminution of the amount of circulating 
blood from hemorrhage, anemia, or cachexia, the arterial tension 
is diminished (hypotension). 

In hypertension the hard pulse is designated the pulsus durus 
in contradistinction to the soft, yielding pulse of hypotension, the 
pulsus mollis. 

Frequently during the course of a continuous fever there is 
noted a pulse of low tension and diminished rate, but of full volume, 
in which there is a reduplication, appreciable to the palpating 
fingers as a minor beat, which is superimposed upon the principal 
beat, constituting the dicrotic pulse. It is to be attributed to ex- 
cessive elasticity of the arteries combined with a more or less 
general relaxation of the smaller arterioles. With the arterial 
system in this state, when the blood enters the arteries from the 
ventricle, these vessels are unduly distended and the contraction 
of the vessels upon the blood column causes the secondary pulse 
wave. 

Duration. — The duration of the j)ulse is determined by the de- 
gree of peripheral resistance, the elasticity of the arterial walls, 
and the duration of ventricular systole. 

The duration of the pulse is increased in the slow, sluggish 
pulsus tardus, which is always associated with increased peripheral 
resistance, due to constriction of the small arterioles, such as occurs 
in arteriosclerosis, chronic renal disease, and angina pectoris. The 
sphygmographic tracing of this pulse shows a gradual upstroke, 
a well sustained plateau and a gradual fall to the base line. This 
slow pulse is observed also in aortic stenosis, in which case it is to 
be ascribed to the rather prolonged systole of the left ventricle 
amid a condition in which arterial tension is reduced. 



PALPATION IN CARDIOVASCULAR DISEASE 



357 



The duration of the pulse is diminished, producing a very rapid 
pulse, the pulsus celer, in conditions associated with diminished 
peripheral resistance as a result of relaxation of the arterioles such 
as occurs in acute febrile states. A form of the pulsus celer, more- 




Fig. 130. — Method of detection of water-hammer pulse. 




Fig. 131. — Testing the symmetry of the radial pulses. 

over, is the water-hammer pulse, or Corrigan pulse, which is ob- 
served in aortic regurgitation. This is a rapid pulse, which is 
characterized by a sudden and full expansion of the artery, fol- 
lowed b}^ a sudden collapse of the vessel under the fingers. 



358 PHYSICAL DIAGNOSIS 

■ * 

Bilateral Symmetry of the Pulse. — Normally the radial pulse is 
exactly similar at the two wrists as to time and as to character. 
This bilateral symmetry of the pulses may, however, be disturbed 
even to the total absence of the pulse at one wrist. Aneurysm of 
the ascending aorta, or innominate artery may retard the right 
radial pulse ; while aneurysm of the subclavian, axillary, or brachial 
arteries may cause retardation upon either side. 

Fracture of the bones of the arm or injuries producing cicatricial 
compression of the artery in the axilla or arm, as well as compres- 
sion by tumors or enlarged glands, will alter the character of the 
pulse at the wrist and cause asymmetry of the pulses. Pneumo- 
thorax or large pleural effusion, by compressing the subclavian 
artery, may cause a retardation or may alter the character of one 
radial pulse. 



CHAPTER XV 
PERCUSSION 

Percussion is employed in the study of cardiovascular disease 
principally in the determination of the position of the heart, in 
the detection of alterations in its shape and size, and in the detec- 
tion of the presence of fluid in the pericardial sac. The determina- 
tion of the size, shape, and position of the heart within the thorax 
is reached by outlining upon the surface of the thorax the areas of 
relative and absolute cardiac dullness. 

Areas of Cardiac Diillness. — ^When the examiner percusses to- 
ward the heart from various points in its vicinity upon the surface 
of the thorax, two changes in the quality of the percussion note are 
observed. As the borders of the heart which are covered by the 
anterior borders of the lungs are approached, the normal vesicular 
resonance becomes impaired, and finally when the portion of the 
heart which lies in direct apposition with the chest wall, uncovered 
by the pulmonary borders is reached, the note becomes frankly flat. 
In this manner there are to be defined upon the anterior surface of 
the thorax two areas of cardiac dullness, the one within the other. 
The inner, representing the area in which the heart is uncovered 
by the anterior borders of the lungs, is termed the area of aljsolute 
cardiac ditlhiess, or the area of cardiac flatness; whereas the periph- 
eral area, representing the portion of the heart which is overlapped 
by the anterior pulmonary borders, is termed the area of relative 
cardiac dullness. 

The area of absolute cardiac dullness, representing the limited 
portion of the right ventricle which is directly apposed to the 
anterior thoracic wall, corresponds to a roughly triangular area 
which is bounded upon the right by a vertical line drawn along 
the left border of the sternum from the level of the fourth costal 
cartilage to the upper border of the sixth costal cartilage, upon the 
left by a line drawn downward with a slight inclination toward the 
left from the junction of the fourth left costal cartilage with the 
sternum to the fifth left interspace midway between the left para- 
sternal and left midclavicular lines, and inferiorly by a line con- 
necting the lower extremities of these two lines. (See Fig. 132.) 

The area of relative cardiac didlness, representing the portion ol 

359 



360 



phYkSical diagnosis 



the heart which is overlapped by the anterior borders of the lungs, 
is bounded upon the right by a vertical line drawn upon the chest 
wall from the upper border of the third costal cartilage near its 
junction with the sternum along the right sternal border to the 
upper border of the sixth costal cartilage, upon the left by a 
slightly curved line having its convexity toward the left and up- 
ward, drawn from the third left chondrosternal junction to the 
fifth intercostal space one-half inch internal to the midclavicular 
line, and inf eriorly by a horizontal line connecting the lower extrem- 
ities of these two lines, from the upper border of the sixth right 




Fig. 132. — Areas of cardiac and hepatic dullness and flatness. 



costal cartilage to the fifth left interspace one-half inch internal 
to the midclavicular line. Thus, the areas roughly represent a 
triangle within a triangle, the area of absolute cardiac dullness 
lying within the area of relative cardiac dullness except inferiorly, 
where the boundaries are the same, and where the fiatness of the 
heart blends imperceptibly with the flatness of the liver. Similarly, 
the right border of the area of relative cardiac dullness joins the 
upper border of the area of hepatic dullness at almost a right angle, 
the angle of pulmonary resonance in the fifth right interspace 
formed in this manner, being termed Ehstein's cardiohepatic angle. 



PERCUSSION IN CARDIOVASCULAR DISEASE 361 

TECHNIC OF CARDIAC PERCUSSION 

The areas of relative and absolute cardiac dullness, represent- 
ing the size, shape, and position of the heart, may be outlined by 
ordinary mediate percussion, or preferably by auscultatory per- 
cussion. 

In mapping out these areas by mediate or auscultatory percus- 
sion, the examiner should commence to percuss from three 
directions in order to fix the upper and the lateral boundaries of 
the regions, employing, as he proceeds, both deep and superficial 
percussion. In fixing the right and left borders, the examiner 
should percuss from the right and left axillary region upon either 
side in the third, fourth, and fifth interspaces toward the pre- 
cordia, employing deep percussion until impairment of the reso- 
nance indicates that the lateral borders of the area of relative 
cardiac dullness have been attained. Having marked these points 
upon the thoracic surface, the examiner continues the percussion 
along the same lines, substituting superficial percussion for the 
deep percussion heretofore employed in order to avoid the elici- 
tation of the resonance of the anterior borders of the lungs, until 
the note which is elicited changes to flatness, indicating that the 
lateral margins of the area of absolute cardiac dullness have been 
reached, representing the portion of the right ventricle which is in 
direct contact with the anterior chest wall. 

After having marked these several points upon the surface of 
the thorax, the examiner, beginning in the left infraclavicular 
region, percusses downward along the interval between the left 
sternal and left parasternal lines, employing in the first instance 
deep percussion, and when the upper limit of the area of relative 
dullness has been attained and marked, continuing with super- 
ficial percussion until the upper limit of the area of absolute 
cardiac dullness is reached, which is similarly marked out upon 
the surface of the thorax. By connecting the points which have 
been marked upon the chest wall, at which the initial change in 
the percussion note was noted in each instance, the areas of 
relative and absolute cardiac dullness are graphically represented 
upon the surface of the thorax. 

VARIATIONS IN THE AREAS OF CARDIAC DULLNESS 

The areas of cardiac dullness as outlined by percussion may be 
increased or may be decreased in one or more directions, or the 
entire area of normal dimensions may be displaced. 



362 



PHYSICAL DIAGNOSIS 



General Increase. — A general increase in the area of cardiac 
dullness in all directions is indicative of cardiac hypertrophy or 
cardiac dilatation, pericarditis with effusion, or a tumor of the 
mediastinal structures which pushes the heart forward. In peri- 
carditis with effusion, the area of dullness is roughly triangular 
or pear-shaped, with the base directed dowuAvard toward the 
diaphragm. 

General Decrease. — A decrease in all of the borders of the area 
of cardiac dullness is indicative of cardiac atrophy or of peri- 
cardial adhesions which draw the heart under the anterior pul- 




Fig. 133. — Extension of cardiac dullness toward the right and toward the left and 
downward in combined right and left ventricular hypertrophy. The dotted lines indicate 
the normal cardiac outline. 



monary borders. Hypertrophic emphysema, by interposing the 
voluminous anterior borders of the lungs between the heart and 
chest wall, causes a general decrease in the area of cardiac dull- 
ness in the absence of cardiac pathology. 

Displacement of the area of cardiac dullness, as indicated by dis- 
placement of the cardiac impulse, occurs in extensive pleurisy with 
effusion, the heart being displaced toward the side of the thorax 
opposite to the effusion. The traction of postpleuritic adhesions 
tends to draw the heart toward the side of the diseased pleura, with 
consequent shifting of the area of cardiac dullness. Subphrenic 



PERCUSSION IN CARDIOVASCULAR DISEASE 



363 



pressure in ascites, tympanites, hepatic enlargement or abscess, 
causes displacement of the area of cardiac dullness upward and 
toward the left. In all of these conditions the entire area of cardiac 
dullness is displaced; but in the absence of coincident disease of 
the heart, it is of normal dimension. 

Upward Increase. — An increase of the area of cardiac dullness 
in an upward direction accompanies pericarditis with effusion, and 
in the presence of aneurysm of the ascending portion or arch of 
the aorta a similar extension upward is observed. In pericarditis 
with effusion the area becomes irregularly triangular or pear- 




Fig. 134. — General extension of cardiac dullness in extensive pericardial effusion. 



shaped with the base directed downward as a result of the char- 
acteristic configuration of the pericardial sac. 

Increase to the Left. — An increase in the area of cardiac dullness 
toward the left occurs with hypertrophy and dilatation of the left 
ventricle, and in cardiac displacement by mediastinal pressure. In 
left ventricular hypertrophy the area is increased downward as 
well as toward the left, occasionally reaching the seventh inter- 
space in the anterior axillary line. 

Increase to the Right. — An extension of the area of cardiac dull- 
ness toward the right, the dullness of the heart encroaching upon 
the normal vesicular resonance of Ebstein's cardiohepatic angle, 
occurs with right ventricular and auricular hypertrophy and dila- 



364 



PHYSICAL DIAGNOSIS 




Fig. 135.- 



-Kxtension of cardiac dullness toward the left and downward in left 
lar hypertrophy. Dotted lines indicate normal cardiac outline. 




Fig. 136. 



-Extension of cardiac dullness toward the right in right ventricular hypertrophy. 
Dotted lines indicate normal cardiac outlines. 



PERCUSSION IN CARDIOVASCULAR DISEASE 365 

tation, and in pericarditis with effusion, constituting in the latter 
disease Eotch's sign. A distended inferior vena cava may be re- 
sponsible for a slight extension of the area of dullness to the right 
of the sternum. When the extension is the result of right ventricu- 
lar hypertrophy there is frequently pulsation of the epigastrium, 
and not infrequently systolic pulsation of the jugular veins as a 
result of tricuspid insufficiency. 

VASCULAR DULLNESS 

In aortic aneurysm the area of vascular dullness which overlies 
the manubrium sterni above the base of the heart is very fre- 
quently increased upon the right side in the first or second inter- 
spaces (Potain's sign). 



CHAPTER XVI 

AUSCULTATION 

Auscultation is employed in the study of the circulatory organs 
to determine the character and intensity of the heart sounds, 
their rhythm, and the presence or absence of certain adventitious 
sounds arising in the heart, pericardium, and arteries. 

THE NORMAL HEART SOUNDS 

The heart in its rhythmic action produces two sounds, which are 
termed the first and the second sound of the heart, respectively. 
The first sound is audible most clearly as a rule in the region of 
the cardiac apex, while the second sound is most clearly audible at 
the base of the heart. 

The first sound of the heart is lower in pitch and of longer dura- 
tion than is the second sound. It has been aptly compared to the 
sound of the word ^'lubb." It is most probably caused by the com- 
bined effect of the closure of the auriculoventricular valves, the 
contraction of the cardiac musculature, and the vibrations of the 
chordae tendineae following coaptation of the valve segments. 

The second sound of the heart is of higher pitch and of shorter 
duration than is the first sound, being closely simulated by the 
sound of the word "clup." The second cardiac sound is unquestion- 
ably produced by the closure of the semilunar valves, which guard 
the orifices of the aorta and the pulmonary artery. The first sound 
of the heart is audible during cardiac systole, and is hence termed 
systolic ; whereas the second sound occurs during diastole, and 
is termed diastolic. In health these two cardiac sounds follow 
each other in regular sequence and are followed by a slight pause. 

The cardiac contractions occur approximately 72 times per 
minute in the normal adult male subject. However, the rate of 
contraction is influenced by sex and age. In the female subject 
the rate is often somewhat higher than it is in the male. Age is 
attended by more definite and distinct variations in the rate of the 
cardiac contractions. Thus at birth the rate is 130 to 140 con- 
tractions per minute, diminishing to 90 to 100 at the fifth year of 
life ; while in the aged the rate is 60 to 72 per minute. 

366 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



367 



AUSCULTATORY VALVE AREAS 

Each of the four valves of the heart has a corresponding area 
at which the sound produced by the closure of the valve in question 
is more distinctly audible than elsewhere upon the surface of the 
thorax. These areas do not correspond to the point of the thor- 
acic wall which is nearest to the anatomic site of the valve. Thus, 
the mitral valve is most clearly audible over the mitral area, 
which is situated over the apex of the heart, although the anatomic 
site of this valve is behind the left half of the sternum at the level 
of the fourth costal cartilage. 




Fig. 137-^. — Auscultatory valve areas of 
the heart. /, Mitral area; 2, tricuspid area; 
S, pulmonary area; 4, aortic area. 



Fig. 137-5. — Auscultatory valve areas of 
the heart, i. Mitral area; 2, tricuspid area; 
5, pulmonary area; 4, aortic area. 



The aortic valve is best examined at the aortic area, just to the 
right of the right sternal border in the second intercostal space, al- 
though the anatomic site of this valve is posterior to the left half of 
the sternum at the level of the third interspace. 

The tricuspid area, at which sounds arising from the tricuspid 
valve are most distinctly audible, is situated over the lower portion 
of the sternum, the anatomic site of this valve being situated be- 
hind the right portion of the sternum between the level of the 
fourth and sixth costal cartilages. 



db« PHYSICAL DIAGNOSIS 

The pulmonary area, at which, sounds generated by the action of 
the pulmonic valve are best appreciated, occupies a point just to 
the left of the left sternal border in the second intercostal space, 
the anatomic site of this valve being posterior to the junction of 
the third left costal cartilage with the sternum. 

Upon examination of the cardiac sounds of a normal subject it 
is noted that the individual sounds arising at the different valve 
areas of the heart are not of uniform intensity. Thus, although the 
first sound of the heart is produced by the combined action of the 
two auriculoventricular valves, it is observed that the first sound 
at the mitral area is lower in pitch and of somewhat greater dura- 
tion than is the tricuspid first sound. Similarly, in the examina- 
tion of the component valves concerned in the production of the 
second sound, it is observed that in an adult subject the second 
sound at the aortic area is of greater intensity and duration than is 
the same sound generated by the pulmonic valve; whereas in a 
child the condition is reversed, the pulmonary sound being more 
intense than is the aortic second sound. 

VARIATIONS IN INTENSITY OF THE CARDIAC SOUNDS 

The intensity of the cardiac sounds as elicited at the various 
valve areas varies in intensity in the presence of disease having 
its inception in the heart or in distant portions of the body. The 
intensity of both sounds or of one sound under these circum- 
stances may be increased or diminished in intensity at one or 
more valve areas. 

Accentuation of Both Sounds. — Both first and second sounds of 
the heart are accentuated in the presence of cardiac hypertrophy, 
in cardiac overaction during exophthalmic goiter, acute febrile 
diseases, following the ingestion of stimulants, and as a result 
of violent physical effort. An apparent accentuation of both 
sounds is occasionally encountered in subjects with very thin 
chest walls, and also in patients in whom fibroid retraction of the 
anterior border of the left lung exposes the heart freely to the 
chest wall. A consolidation of the lappet of lung overlying the 
heart transmits the normal cardiac sounds to the surface of the 
thorax with undue intensity, simulating a true accentuation of 
the tones. 

Diminished Intensity of Both Sounds. — In robust subjects with 
thick chest walls, in the presence of pericarditis with effusion, 
when a certain amount of fluid intervenes between the heart and 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



369 



chest wall, and in hypertrophic emphysema when the distended 
anterior borders of the hmgs intervene between the heart and 
thoracic wall, the cardiac sonnds are enfeebled, without possess- 
ing any reference to the state of the myocardium. In cardiac 
dilatation and in myocardial degeneration, on the other hand, 



A. B. 

Fig. 138. — A. Normal first and second sounds. B. Accentuated first sound. 

the sounds are weakened from impairment of the integrity of the 
myocardium. General asthenia from long-continued wasting 
disease causes a weakening of both cardiac sounds. 

Accentuation of the First Sound, — An increase in the intensity 
of the first sound of the heart at the mitral area, of moderately 
increased duration, followed by an abnormally intense aortic 
second sound, is indicative of left ventricular hypertrophy. When 
cardiac dilatation is imminent, the first sound as elicited at the 
apex is loud but is of brief duration and has engrafted upon it 
the valvular quality of the normal second sound. 

Diminished Intensity of the First Sound. — Myocardial degen- 
eration and cardiac dilatation lead to diminution in the intensity 
of the first sound at the apex. Similarlj^ the asthenia of chronic 



A. B. 

Fig. 139. — A. Normal first and second sounds. B. Diminished first sound. 

wasting disease, anemia, and prolonged fevers leads to weakening 
of this sound, the sound acquiring a valvular quality analogous 
to that of the normal second sound of the heart. 

Accentuation of the Aortic Sound.^The aortic sound is in- 
creased in intensity in all bodily states which are attended by 
increased tension in the greater circulation. Hence it is en- 
countered in cases of angiospasm due to temporary vasoconstric- 
tion, in arteriosclerosis, chronic interstitial nephritis, uremia, and 



370 



PHYSICAL DIAGNOSIS 



in apoplexy. When the root of the aorta and the semilunar 
valves participate in general arteriosclerosis, the aortic sound is 
accentuated, with metallic, clinking quality. In hypertrophy of 



A. B. 

Fig. 140. — A. Normal first and second sounds. B. Accentuated second sound. 

the left ventricle the aortic second sound is accentuated, to be- 
come enfeebled with the inception of cardiac dilatation. 

Diminished Intensity of the Aortic Sound. — Enfeeblement of 
the aortic sound accompanies lowering of the blood pressure in 
the greater circulation incident to profuse hemorrhage, anemia, 
relaxation of the periiDheral arterioles, and when, as a result of 



A. B. 

Fig. 141. — A. Normal first and second sound. B. Diminished second sound. 

mitral or aortic stenosis or insufficiency, a diminished quantity of 
blood is ejected into the aorta during ventricular systole. Natu- 
rally the aortic sound is enfeebled in conditions which impair 
the integrity of the myocardium of the left ventricle, as in cardiac 
dilatation and myocardial degeneration. 

Accentuation of the Pulmonic Sound. — Conditions which raise 
the blood, pressure in the pulmonary circulation, as in the case 
of obstructive pulmonary disease such as cirrhosis of the lung, 
pneumonia, phthisis, and emphysema, produce accentuation of 
the second sound at the pulmonary area. Similarly, regurgitant 
and stenotic lesions at the mitral or aortic valve, by permitting 
the blood to accumulate in the pulmonary circuit and thus raising 
the blood pressure here, tend toward a similar accentuation. 
Tumors or enlarged glands pressing upon the great veins return- 
ing the blood from the lungs to the left heart operate in the same 
manner. In right ventricular hypertrophy from any cause the 
second sound at the pulmonary area is accentuated. 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



371 



Diminished Intensity of the Pulmonic Sound. — Weakening or 
failure of the pulmonic sound is indicative of failure of the right 
heart. When a pulmonic sound which has been accentuated be- 
comes weak, it indicates right ventricular dilatation or the devel- 
opment of tricuspid regurgitation. 

REDUPLICATION OF THE HEART SOUNDS 

Either the first or the second sound of the heart may under 
certain circumstances become doubled or reduplicated. Ordina- 
rily the examiner encounters a reduplication of either the first or the 
second sound alone ; very rarely is there reduplication of both 
sounds. If the first sound is reduplicated, the sound which is elicited 
resembles the words ^'lur-rup-dup, " Avhereas if the second sound 
is reduplicated alone, the sound resembles the spoken words 
'4ub-durrup." In certain instances these sounds are so accented 
as to resemble the sound which is produced by the gallop of a 



A. B 

Fig. 142. — A. Normal first and second sounds. B. Redviplicated first sound. 

horse, under which circumstances the sound has been termed 
''gallop-rhythm" or ''canter-rhythm," or the "bruit de galop." 

Reduplication of the first sound of the heart is only rarely en- 
countered, and the mechanism of its production is beset with diffi- 
culties. It has been believed that the reduplication is due to 
asynchronous closure of the mitral and tricuspid valves, owing to 
asynchronous systole of the right and left ventricles. The plienome- 
non has also been referred to unequal tension of the leafiets of the 
two auriculoventricular valves. The sound produced by redupli- 
cation of the first sound of the heart is frequently confused with a 
presystolic mitral murmur which is followed by a normal first 
sound. Reduplication of the first sound may be a sign of mitral 
stenosis, or it may develop on account of lesions of the auriculo- 
ventricular valves during failure of compensation. 

Reduplication of the second sound of the heart is to be attributed 
to asynchronous closure of the aortic and pulmonary valves as a 
result of unequal tension in the greater and lesser circulations. 



372 PHYSICAL DIAGNOSIS 

■ » 

Hence, a reduplication of the sound is noted in all states which 
raise the pulmonary blood pressure, as in emphysema, cirrhosis of 
the lung, pneumonia, and left-sided valvular heart disease, as well 
as in association with arteriosclerosis and chronic interstitial nephri- 
tis, raising the pressure in the general circulation. Reduplication 
of the second sound has occasionally been noted in normal subjects 
during deep inspiration. 

CARDIAC ARRHYTHMIA 

Clinical Attributes of the Myocardium 

The myocardium possesses certain inherent and intrinsic prop- 
erties which are not shared by the musculature of other portions 
of the body. These properties comprise rhythmicity, tonicity, irri- 
tability, conductivity, and automaticity. 

Throughout life the heart undergoes a series of rhythmical con- 
tractions, ventricular systole following auricular systole in regular 



A. B. 

Fig. 143. — A. Normal first and second sounds. B. Reduplicated and accentuated 

second sovtnd. 

and orderly rhythm. This rhythmicity pertains to both the force 
and the time sequence of the cardiac contractions. This series of 
contractions and relaxations of the myocardium, punctuated by 
definite periods of repose, constitutes the cardiac cycle. Assuming 
that the regular series of events occurs 72 times per minute, the 
time which is consumed by each of the components of the cycle may 
be taken to be as follows: the entire cycle consumes 0.8 second; 
auricular systole consumes 0.1 second; ventricular systole con- 
sumes 0.3 second; and the period of repose of the entire heart 
consumes 0.4 second. 

The myocardium constantly maintains a state of partial or poten- 
tial contraction, constituting the tone of the heart. By virtue of 
this tone the capacity of the chambers of the heart and the total 
size of the organ during diastole are not as great as would obtain 
in the presence of complete relaxation of the myocardium during 
diastole. Possessed by all portions of the myocardium, the greatest 



AUSCULTATION IN CARDIOVASCULAR DISEASE 373 

variations in tonicity are encountered in the auricles, in which 
Botazzi has demonstrated that the variations of tone are periodic. 
The myocardium possesses an inherent irritability, or ability to 
respond to extracardiac stimuli, the degree of irritability varying 
in different portions of the organ. Unlike skeletal muscle, the 
strength of the response of the myocardium to a stimulus which 
reaches it bears no definite relation to the degree of stimulation; 
but the response is maximal to all stimuli, be they powerful or 
feeble. The most feeble adequate stimulus when applied to the 
myocardium results in as powerful a contraction as would a 
stronger stimulus, and an increase in the degree of stimulation does 
not magnify the degree of the response. Moreover, after a con- 
traction has been excited by a primary stimulation, there is no 
response to a second stimulus which reaches the myocardium be- 
tween the inception and completion of the primary response, the 
so-called refractory period of the heart. If, however, a contraction 
be initiated earlier in the cycle than it would automatically occur, 
the succeeding pause before the next regular contraction is longer, 
constituting the so-called compensatory pause of the heart, a very 
important fact for consideration in the study of cardiac arrhyth- 
mia. 

The degree of irritability of the myocardium is influenced by the 
state of nutrition of the cardiac musculature, as also reflexly by 
disturbances in remote organs of the body. Englemann designates 
as lathmotropic all stimuli which influence the irritability of the 
myocardium, positive bathmotropic stimuli increasing the irri- 
tability of the musculature, and negative stimuli of the same char- 
acter inhibiting the irritability of the heart. Similarly, he 
designates as inotropic all impulses which influence the force of the 
cardiac contractions, positive inotropic impulses increasing the 
power and amplitude of the contractions, and negative inotropic 
impulses impairing the degree of contractility. 

The myocardium also possesses the property of conductivity, by 
virtue of which impulses originating in one portion of the muscula- 
ture are conducted to other portions. The conduction path for 
the cardiac impulse is represented by a bundle of specialized mus- 
cular fibers, the auriculoventricular bundle of His. The highly 
differentiated fibers constituting this bundle arise in the wall of the 
right auricle and the interauricular septum, whence branches are 
sent upward as far as the great venous trunks which empty their 
contents into the right auricle. The bundle passes downward to 
the interventricular septum, where it divides, sending branches to 



374 PHYSICAL DIAGNOSIS 

" * 

each ventricle which after dividing dichotomously eventually ter- 
minate in the Purkinje cells. 

By way of the bundle of His the muscular contractions which 
are rhythmically initiated through the sinus node are transmitted 
downward over the auricles and the ventricles, resulting in the 
regular and orderly systole of these chambers of the heart. 

Impulses which influence the transmission of the muscular con- 
traction wave are termed droniotropic, positive dromotropic im- 
pulses resulting in an increased rapidity of propagation of the 
wave ; and negative dromotropic impulses retarding the conduction 
of the wave. Erlanger has demonstrated that upon clamping the 
bundle of His the mammalian heart exhibits the phenomenon of 
heart-block, a condition which becomes an occasional cause of ar- 
rhythmia. 

The myocardium exhibits the powder of automatic action in 
regular rhythm, whether the automaticity be assumed to be of 
myogenic or neurogenic origin. 

The action of the heart is influenced and is regulated to a 
large degree by its nerve supply from the cerebrospinal and 
sympathetic nervous systems. The entire nerve supply of the 
heart is centrifugal with the exception of the cardiac depressor 
nerve, and the reflex arc of this nerve is completed by the vagus. 
Lesions of the medullary center of the latter nerve or compres* 
sion of the trunk of the nerve by lesions of adjacent structures 
result in arrythmia. Similarly, reflex irritation of the sympa- 
thetic nervous system by lesions residing in the thorax, abdomen, 
or pelvis may be the underlying cause of arrhythmia, as may also 
alterations in the integrity of the myocardium. 

Impulses which influence the cardiac rate are termed chrono- 
tropic, positive impulses producing acceleration of the heart rate, 
and negative impulses reducing the number of contractions. 
Cardiac arrhythmia may appertain either to the rate or to the 
force of the contractions. 

Types of Arrhythmia 

Simple Arrhythmia. — This, the most commonly encountered 
type of cardiac arrhythmia, is characterized by variations in both 
the frequency and the force of the cardiac contractions. When 
only the force of the contractions is involved the clinical result 
is the pulsus alternans. When, on the contrary, the frequency of 
the contraction alone is involved, the condition presents variations 
from the normal orderly rhythm of the cardiac action, which in 



AUSCULTATION IN CARDIOVASCULAR DISEASE 375 

certain instances is rhythmically irregular, as manifested clinically 
by the pulsus higemimis or the pulsus trigeminus, 

Intermittence. — In certain cases of arrhythmia the predominant 
feature is the occasional omission of ventricular systole, as evi- 
denced by the pulsus intermittens. In the study of cases of this 
type the radial pulse should be palpated in conjunction with 
auscultation of the precordia in order to determine whether the 
omission of the radial pulse is due to the omission of ventricular 
systole or whether caused by a ventricular systole which is too 
feeble to produce a radial pulse (false intermission). 

Respiratory Arrhythmia. — This ty^e of arrythmia bears a 
definite and constant relation to the phases of the respiratory 
cycle, and has been attributed to accentuation of the normal 
cardiorespiratory reflex. The normal ratio between the duration 
of the phases of the cardiac cycle as observed during inspiration 
and expiration is disturbed, and in the words of MacKenzie ''the 
shortening of the period of the cardiac cycle takes place almost 
entirely at the expense of the diastolic portion." Slow and full 
inspiration accentuates the irregularity, the clinical result being 
the pulsus respiratorius. 

Respiratory arrhythmia is encountered in many normal subjects 
and frequently as a postfebrile condition, without possessing un- 
toward significance. On the contrary, it is frequently an accom- 
paniment of chronic meningeal disease, and has been noted in 
neurasthenic patients and in conditions of secondary anemia. 

Tachycardia (Polysystole; Rapid Heart). — Elevations of the 
normal heart rate are of frequent occurrence, and possess a varied 
significance. Increased heart rate is a constant accompaniment 
of elevations of temperature, the degree of polysystole usually 
bearing a definite relation to the elevation of the temperature. 
Excessive physical exertion is normally attended by a corre- 
sponding rise in the rate of the cardiac contraction ; and a similar 
increase accompanies the excessive use of tobacco and the in- 
gestion of large quantities of alcohol, tea, or cotfee. Tachycardia 
may be essential, reflex, or paroxysmal. 

Essential tachycardia accompanies organic change in the myo- 
cardium or the cardiac valves. It is encountered in acute myo- 
carditis, myocardial degeneration, and in chronic valvular disease 
with inadequate compensation. 

Reflex tachycardia occurs as the result of lesions of the vagus 
centers or compression of these centers or by pressure exerted upon 
the vagus trunks in their course by mediastinal tumor or enlarged 



o7b PHYSICAL DIAGNOSIS 

glands, and as a result of neuritis of the vagus nerve. Eeflex tachy- 
cardia also is a frequent manifestation of reflex irritation of the 
sympathetic innervation of the heart by thoracic, abdominal or 
pelvic disease, as well as during the course of exophthalmic goiter 
and at the menopause. 

Tachycardia may or may not be attended by subjective symp- 
toms. Not infrequently the patient is not aware of its presence. 
In other instances there is precordial distress with a sense of fatigue 
with dizziness and a tendency to faint upon assuming the erect 
posture. The pulse presents varying degrees of rapidity, usually 
ranging between 120 and 160, and is of the type of the pulsus celer. 
Save in cases of extensive duration, the pulse volume is adequately 
maintained, and there is absence of edema or other signs of venous 
stasis. 

Paroxysmal tachycardia, first described as a clinical entity by 
Proebsting, is characterized by paroxysms of very rapid cardiac 
action, the attack beginning very abruptly, persisting for a variable 
length of time, and ceasing as abruptly as it began. The rhythm 
is deranged chiefly during the onset and termination of the attack. 
The heart rate is the predominant feature of the attack, often 
exceeding 200 contractions to the minute. Usually of brief dura- 
tion, consuming a few seconds or minutes, the attack may persist 
for hours or for days. During the paroxysm there is not in- 
frequently precordial distress, pallor, dyspnea and faintness, these 
symptoms becoming ameliorated upon assuming the recumbent 
posture. Usually observed in adults who are free from cardiac 
pathology, the attacks may affect persons of any age, and may re- 
cur at varying intervals for months or years. 

Paroxysmal tachycardia has been noted in connection with the 
gastric crises of tabes dorsalis. It has also been seen in the presence 
of sclerosis of the coronary arteries, and in chronic valvular disease, 
particularly in association with stenotic lesions. 

Palpitation.— Palpitation is a form of arrhythmia affecting prin- 
cipally the force of the cardiac action, though not infrequently 
it is attended by disturbances in the rate and rhythm of the heart. 
The predominant feature of the condition is that the patient is 
painfully conscious of the presence of the tumultuous heart action. 
During the height of the attack there is visible pulsation of the 
precordia and throbbing of the carotids. Occurring at irregular 
intervals, the paroxysms last a variable time, from a few minutes 
to several hours. Auscultation of the precordia reveals the 



AUSCULTATION IN CARDIOVASCULAR DISEASE 377 

tumultuous character of the ventricular systole, but in the absence 
of coincident organic cardiac disease, murmurs are absent. 

Occurring in many nervous young adults who are apparently 
in excellent physical state, palpitation is often noted as well at 
puberty, during the climacterium, at the onset of menstruation, 
during attacks of indigestion, and following the ingestion of 
excessive amounts of tea, coffee, or alcohol. Neurasthenic subjects 
are very subject to attacks of palpitation, as are also excessive users 
of tobacco. Although usually a purely functional disorder, pal- 
pitation has been observed in organic disease of the heart, when 
cardiac failure was imminent. 

Bradycardia (Slow Heart; Brachycardia) . — Abnormally slow 
cardiac action, the contractions falling below 60 to the minute, 
may be encountered as a physiologic or a pathologic phenomenon. 

Physiologic bradycardia is a constant accompaniment of ad- 
vanced age; whereas in other instances it is an inherent physical 
characteristic. During the puerperal state and during labor 
bradycardia frequently obtains, without possessing untoward 
significance. Bradycardia is physiologic during hunger and ex- 
haustion. Strictly speaking, the persistent bradycardia which is 
often noted during convalescence from febrile diseases, as typhoid 
fever, acute rheumatic fever, and pneumonia, in the case of 
robust young subjects, is physiologic and an evidence of exhaus- 
tion. 

Pathologic bradycardia characterizes a great variety of dis- 
eases. It is an accompaniment of increased intracranial tension 
in meningitis, cerebral abscess or tumor, cerebral hemorrhage, 
and depressed fracture of the skull. In cardiovascular disease 
bradycardia is not infrequent in the presence of aortic stenosis 
and extensive myocardial degeneration, as well as in coronary 
arterial sclerosis and Stokes-Adams' disease. In disease of the 
urinary system, bradycardia is noted in chronic interstitial 
nephritis, during renal colic, and in uremia. In diseases of the 
digestive tract, slow cardiac action is noted in connection with 
chronic gastric or intestinal indigestion, ulcer and carcinoma of 
the stomach, with autointoxication, in acute or chronic jaundice, 
and during gallstone colic. In chronic intoxication from lead, 
and in intoxication from alcohol, opium, or digitalis, the cardiac 
action is often slowed to a remarkable degree. Certain constitu- 
tional diseases as diabetes mellitus and essential anemia are 
marked by a reduction in the heart rate. Bradycardia may be 
due to irritation of the trunk of the vagus nerve by mediastinal 



378 PHYSICAL DIAGNOSIS 

tumor, enlarged mediastinal glands, aortic aneurysm, or ex- 
tensive empyema. Disease of the medulla or compression or 
injury of the cervical cord may be responsible for bradycardia. 

Heart-Block. — Heart-block, the basis of which is a diminution 
in the conductivity of the auriculoventricular bundle of His, may 
be partial or complete. 

In partial heart-Mock only a portion of the auricular contraction 
waves are conducted to the ventricles, resulting in a diminution 
in the number of ventricular contractions, the ventricles contract- 
ing only with every second, third, or fourth systole of the auricles. 

In complete heart-Mock all of the auricular impulses are in- 
hibited with the result that the auricles and ventricles contract 
independently and with a separate rhythm. 

The causative lesion in cases of advanced age is usually sclerosis 
of the myocardium, which is part and parcel of general arterio- 
sclerosis. In the majority of cases developing at an earlier age the 
underlying cause has been syphilis ; but Edes and Councilman have 
described a neurotic group in which no demonstrable lesions have 
been found at necropsy. 

The clinical manifestation of heart-block is the Stokes-Adams 
syndrome, which is characterized by bradycardia, auricular pulsa- 
tions in the jugular veins, and signs of cerebral anemia, as 
evinced by vertigo, transitory unconsciousness, Cheyne-Stokes' 
respiration, apoplectiform seizures, and transient paralyses. 

Extras ystolic Arrhythmia. — The injection of extr asystole into 
the normal regular and orderly sequence of the cardiac cycle is 
noted in connection with puberty and the climacterium, after exces- 
sive indulgence in tobacco, tea, coffee, or alcohol, during convales- 
cence from acute infections, and in elderly persons with arterial 
sclerosis. As stated, the myocardium always contracts with a maxi- 
mum response regardless of the intensity of the stimulus which 
excites the contraction ; and a stimulus which reaches the auricle or 
ventricle between the reception of the primary stimulus and the 
completion of the consequent contraction is without effect upon 
the myocardium. Moreover, when under these conditions an 
extrasystole is injected into the cardiac cycle, causing a diminu- 
tion in the physiologic period of repose, then the succeeding pause 
preceding the next regular systole is prolonged. 

The normal stimulus for systole arises in the sinus node ; and 
the term extrasystole should be limited to systole which is called 
forth by a stimulus emanating from an abnormal portion of the 
myocardium. Extrasystole may involve the ventricle alone, con- 



AUSCULTATION IN CARDIOVASCULAR DISEASE 379 

stituting ventricular extrasy stole; the irregularity may be limited 
entirely to the auricle, auricular extrasy stole; or the two may occur 
in conjunction, constituting auriculo ventricular extrasystole. 

In ventricular extrasystole the impulse is assumed to originate in 
the auriculoventricular bundle of His below the level of the sinus 
node. The initial impulse in auricular extrasystole arises in the 
auricular wall below the sinus node. Conflicting views are enter- 
tained as to the source of the exciting stimulus in the case of the 
mixed, auriculoventricular type of extrasystolic arrhythmia. Mac- 
Kenzie holds that the impulse arises in the node of Tawara ; while 
other investigators have attributed the condition to the presence of 
ventricular extrasystole in which a retrograde impulse causes co- 
incident auricular extrasystole. 

In extrasystolic arrhythmia the pulse is of the intermittent type, 
the pulsus intermittens. In certain cases the arrhythmia assumes 
an allorrhythmic type, resulting clinically in the pulsus higeminus 
or the pulsus trigeminus. A very frequent form of cardiac ar- 
rhythmia, a form which does not as a rule imply organic change in 
the myocardium, extrasystolic arrhythmia may or may not be at- 
tended by subjective symptoms. When present, the latter usually 
comprise precordial sensations varying from mere "consciousness" 
of cardiac action to extreme palpitation with transient faintness. 
The arrhythmia is readily detected by auscultation of the pre- 
cordia, the distinguishing feature of the disorder being the inter- 
ruption of the normal rhythm of the heart by the injection of two 
short sounds, followed by a compensatory pause. 

Auricular Fibrillation.^Fibrillation of the auricle, attended by 
the pulsus irregularis perpetuus, has been noted most frequently in 
association with mitral stenosis, but also with mitral regurgitation, 
chronic interstitial myocarditis, and infrequently in aortic valvular 
disease. The arrhythmia is noted in adults and persons past middle 
life, frequently with a history of rheumatism or chorea. Males 
present the condition more frequently than do female subjects. 

During the attack the cardiac action is continuously irregular, 
delirium cordis. The pulse is rapid, the frequency varying between 
wide limitations, and is extremely irregular both in frequency and 
volume. The attacks, which often recur for many years, are ushered 
in by sensations of precordial distress, dyspnea which may amount 
to orthopnea, and transient faintness and cyanosis. 

Embryocardia. — In the course of prolonged continuous fevers, 
and in the presence of organic cardiac disease with imperfect 
compensation, and in arteriosclerosis with impending cardiac 



380 PHYSICAL DIAGNOSIS 

failure, the rhythm of the cardiac action is altered, the heart 
sounds simulating to a varying degree the tones of the fetal 
heart. In this type of arrhythmia the first and second sounds of 
the heart approximate one another in intensity and duration, and 
are separated by pauses of equal duration as the result of pro- 
longation of the first period of repose between auricular and 
ventricular systole and shortening of the second period of repose 
following ventricular systole. 

ADVENTITIOUS SOUNDS 

In disease of the circulatory organs various adventitious sounds 
are generated within the chambers of the heart (endocardial), or 
outside of the heart in the pericardium, the lung, pleura, or ves- 
sels (Exocardial). 

ENDOCARDIAL MURMURS 

■ Murmurs are adventitious sounds, arising within the chambers 
of the heart, which may be superadded to the normal cardiac 
sounds, or which may entirely replace these sounds. The manner 
of generation of endocardial murmurs may be explained upon 
certain physical principles. They are produced by irregularities in 
the movement, of the blood through the chambers and orifices of the 
heart, by virtue of which the blood is set in vibration or eddies, 
which when transmitted through the thoracic wall are audible as 
murmurs and palpable as thrills. As long as normal blood passes 
through a normal heart with normal endocardium and normal 
valves, no sound is generated save the sounds which are normally 
produced by the closure or coaptation of the valve segments. 
But when the blood is forced through a narrowed or stenotic 
orifice into a wider chamber beyond, or when the blood is per- 
mitted by an incompetent valve to regurgitate into a chamber 
of the heart, the blood column is Avhipped into eddies, the so- 
called ''fluid veins," which throw the blood into rapid vibrations 
which are transmitted to the ear as a perceptible sound, the 
endocardial murmur. 

The murmur is ordinarily propagated in the direction of the 
blood stream. Thus in the case of the murmur of aortic stenosis 
the murmur is transmitted in the direction of the blood current ; 
namely, upward into the carotid arteries ; whereas in the case of 
the murmur or aortic regurgitation the murmur is transmitted in 



AUSCULTATION IN CARDIOVASCULAR DISEASE 381 

the direction of the regurgitating blood stream; namely, down- 
ward and toward the left axilla. 

The relative density of the blood also influences the generation 
of endocardial murmurs. The thinner the blood, the greater is the 
ease with which fluid veins are produced in the blood stream, a 
fact which serves to partially explain the great frequency of 
murmurs occurring in anemic states. Moreover, a certain degree 
of arterial pressure or of endocardial pressure is essential to the 
generation of a murmur. This is evinced by the fact that endo- 
cardial murmurs remain distinct and strong as long as cardiac 
compensation is maintained, to become indistinct or lost Avith 
the supervention of cardiac dilatation. 



Fig. 144. — Illustrating the physical basis of murmurs generated by diminution of lumen. 

CHARACTERISTICS OF ENDOCARDIAL MURMURS 

Endocardial murmurs possess certain essential characteristics 
or properties which are and remain characteristic of the murmurs 
arising at the several valves of the heart; and by a study of these 
properties the murmurs may be distinguished and their site of 
production may be determined. 

Point of Maximum Intensity .^ — Every endocardial murmur has 
a point of maximum intensity, the point at which it is most clearly 
audible upon auscultation of the precordia. These points corre- 
spond very accurately as a rule with the points at which the 
closure of the normal valve in question is best heard; that is, in 
the four acoustic valve areas. Thus, a murmur which is gener- 
ated at the mitral valve is usually heard with the greatest in- 
tensity at the mitral area, over the apex of the heart in the fifth 
left interspace ; whereas a murmur which is generated at the 
aortic valve is most clearly audible at the aortic valve area below the 
second right costal cartilage near the right sternal margin. 

This selective transmission of the sound in its maximum in- 
tensity to the surface of the thorax in the case of the different 
murmurs is accounted for bj^ the fact that the sound is most 
likely to travel in the direction of the fluid vein, and by the 
difference in the conductivity of the component portions of the 



382 PHYSICAL DIAGNOSIS 

thorax, and the differences in the distance of the cavity in which 
the nuirmur is generated from the surface of the thorax. 

Line of Transmission. — Most organic endocardial murmurs are 
audible not only at their points of maximum intensity, but they 
are transmitted or propagated thence in directions which vary 
in the individual murmurs, constituting the line of transmission 
or the line of propagation of the murmur. The direction in which 
a given murmur is to be transmitted is determined by the direc- 
tion of the blood stream, and the relative conductivity of the 
adjacent thoracic structures. 

The Time of Murmurs. — Every endocardial murmur bears a 
definite temporal relation to the events of the cardiac cycle. A 
murmur which is generated by ventricular systole and which is 
audible during cardiac systole is termed a systolic murmur; while 
a murmur developing and audible during diastole is designated a 
diastolic murmur. Similarly a murmur which is audible just prior 
to systole is termed a presystolic murmur. 

The Quality of Murmurs. — The quality of an endocardial mur- 
mur is commonly described as harsh and rasping, or as soft, 
blowing, or musical. The quality of a murmur possesses diag- 
nostic significance and should in all instances be carefully studied. 
As a general rule, a harsh, unmusical murmur accompanies 
stenotic lesions, while soft musical or blowing murmurs char- 
acterize regurgitant lesions of the cardiac valves. While study- 
ing the quality of the murmur the examiner should also endeavor 
to determine whether the murmur is followed by the normal 
cardiac sound or whether it entirely replaces this sound, as a 
murmur which merely accompanies or is superadded to the normal 
cardiac sound is not of as grave prognostic significance as is a 
murmur which entirely replaces the sound of the heart. 

The Intensity of Murmurs. — Just as a certain degree of endo- 
cardial pressure is essential to the development of a murmur, so 
also the intensity of a murmur is a good index of the endocardiac 
pressure and hence indirectly of the state of the myocardium. 
Thus, a loud murmur suggests the presence of cardiac hyper- 
trophy, while a faintly audible murmur is very suggestive of 
cardiac dilatation. Moreover, a change in the intensity of a 
murmur during daily examinations affords an index to the reserve 
power of the heart, a change from a loud to a soft, faint murmur 
suggesting a failing heart, while a steady increase in the intensity 
of a murmur from day to day is suggestive of cardiac improve- 
ment. 



AUSCULTATION IN CARDIOVASCULAR DISEASE 383 

MITRAL MURMURS 

Murmurs arising at the mitral valve are presystolic or systolic, 
as they are audible just prior to or during ventricular systole. 

Mitral Presystolic Murmur. — A presystolic murmur at the 
mitral area is indicative of mitral stenosis, the narrowing of the 
orifice whipping the blood stream into fluid veins which produce 
a murmur, which is audible just prior to the first sound of the 
heart. The murmur is commonly followed by a sharp, snappy 
first sound; but as mitral stenosis and insufficiency frequently 
coexist, the regurgitant murmur frequently masks or impairs the 
first sound of the heart at the apex. The point of maximum 



Fig. 145-^. — Point of maximum intensity of Fig. 145-5. — Point of maximum intensity of 
mitral presystolic murmur. mitral presystolic murmur. 

intensity of the murmur is localized at the mitral area in the fifth 
left interspace over the cardiac apex, whence the murmur is not 
transmitted. The mitral presystolic murmur is loud, harsh, and 
crescendo in quality, increasing in intensity to its abrupt termina- 
tion, usually in a sharp first sound. The murmur is quite con- 
stantly accompanied by a thrill. The pulmonic second sound is 
commonly accentuated as a result of increased blood pressure in 
the pulmonary circuit. 



384 PHYSICAL DIAGNOSIS 

■ * 

The murmur of mitral stenosis must be differentiated from the 
Flint murmur^ which is also audible at the mitral area in cases of 
aortic regurgitation just prior to ventricular systole. The manner 
of production of this murmur is a matter of dispute, but the usual 
explanation is that in this disease the aortic cusp of the mitral 
valve becomes the target for two streams of blood entering the 
ventricle from opposite directions, one entering from the left auricle 
and the other regurgitating from the aorta, and is thereby thrown 
into vibrations, which are audible as a late diastolic or presystolic 
murmur. The Flint murmur has its point of maximum intensity at 
the mitral area; it is audible during late diastole or just prior to 
systole; it is not transmitted from the apical area; but it has not 
the ingravescent or crescendo quality of the mitral stenotic mur- 
mur; it is not followed by a snappy first sound; it is not accom- 
panied by a thrill ; and it has associated with it other signs of aortic 
regurgitation, as pulsation in the arteries of the neck, the water- 
hammer or Corrigan pulse, and the capillary pulse of Quincke. 

Mitral Systolic Murmur. — A mitral systolic murmur is indica- 
tive of incompetence or insufficiency of the mitral valve as a 
result of organic deformity of the valve segments, or stretching 
of the mitral ring as a result of which the edges of the cusps 
cannot be brought into close coaptation during ventricular 
systole, and permit reflux of blood into the left auricle. 

The point of maximum intensity of the murmur is localized in 
the mitral area over the cardiac apex, whence it is transmitted 
toward the left axillary region, not infrequently as far as the 
angle of the scapula. The murmur occurs during ventricular 
systole, masking or replacing the first sound of the heart at the 
apex. In quality the murmur is soft and sometimes musical, or 
blowing, and of low pitch. The intensity of the mitral systolic 
murmur varies with the state of the ventricular musculature, 
remaining strong as long as compensation is maintained, and 
becoming weak or disappearing when dilatation supervenes. 

The pulmonic second sound is accentuated, owing to right ven- 
tricular hypertrophy and as a result of the raised arterial pres- 
sure in the pulmonary circulation; and in long standing cases 
with organic change in the mitral valve, a safety-valve leak 
commonly develops at the tricuspid valve. The murmur of mitral 
regurgitation is less constantly accompanied by a thrill than is 
the murmur of stenosis of this valve. 

Aortic Murmurs. — Murmurs arising at the aortic orifice are 
systolic and diastolic, as they are occasioned by an obstruction 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



385 



to the free flow of blood from the ventricle into the aorta during 
ventricular systole, or by lesions of the valve which by impairing its 
integrity permit a portion of the blood ejected during systole to 
regurgitate into the ventricle during diastole. 

Aortic Systolic Murmur.^A systolic murmur at the aortic valve 
area is usually indicative of an obstacle to the passage of blood into 
the aorta during ventricular systole. This obstruction is usually 
a sequence of ulcerative endocarditis, which leaves adhesions be- 
tween the edges of the cusps, thus narrowing the orifice. A similar 
murmur may be caused by relative stenosis, in which event the 




Fig-. 146-A. — Point of maximum inten- 
sity and line of transmission of mitral sys- 
tolic mvirmur. 



Fig. 146-B. — Point of maximum inten- 
sity and line of transmission of mitral sys- 
tolic murmur. 



aortic ring and cusps are normal, but there is a dilatation or 
aneurysm of the aorta immediately beyond the orifice of the valve. 
A systolic murmur at the aortic area may be indicative also of 
aortic roughening. 

The systolic aortic murmur is most clearly audible at the aortic 
area in the second right interspace close to the sternum, whence it 
is transmitted upward into the carotid arteries in the root of the 
neck. The murmur develops during ventricular systole and may or 
may not be followed by a clear second sound of the heart. In 
murmurs which are due to deformed valve cusps the second sound 



386 



PHYSICAL DIAGNOSIS 



is usually replaced by a diastolic murmur due to aortic regurgita- 
tion; but in cases in which the systolic murmur is caused by 
dilatation or roughening of the aortic wall the second sound is 
clearly audible. The murmur is loud, harsh, and unmusical, the 
intensity depending upon the degree of contractile power of the 
ventricular musculature. 

Aortic Diastolic Murmur. — A diastolic murmur at the aortic 
area is indicative of aortic insufficiency, aortic regurgitation, or 
Corrigan's disease. The underlying lesion may be a shrinking 
and thickening of the cusps, rupture or perforation of a cusp, or 




Fig. 147-A. — Point of maximum inten- 
sity and line of transmission of aortic sys- 
tolic mtirmur. 



Fig. 147 -B. — Point of maximum inten- 
sity and line of transmission of aortic sys- 
tolic murmur. 



the presence of warty verrucosities upon the cusps which prevent 
their close and accurate coaptation during diastole. Or again, 
the murmur may arise as the result of the inability of normal 
valve cusps to close an abnormally large aortic orifice, constitut- 
ing in this instance relative aortic insufficiency. 

The aortic diastolic murmur is most distinctly audible at the 
aortic area, as a rule, and it is propagated therefrom in a direction 
ranging downward obliquely across the sternum toward the 
cardiac apex. While this murmur is usually most intense at the 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



387 



aortic area, in certain instances it is to be heard most clearly over 
the upper portion of the giadiolns, just below the Angle of Louis, 
or over the cardiac apex, whence it is transmitted downward and 
toward the left axilla. The murmur occurs during diastole, 
masking or replacing the second sound of the heart at the aortic 
area. The murmur is loud and blowing, but is not harsh or un- 
musical. 

While the diastolic murmur of aortic insufficiency may occur 
alone, it is not infrequently accompanied by a systolic aortic 
murmur, due to aortic stenosis, a deformity of the aortic vah^e 
underlying both conditions and causing both stenosis and insuffi- 





Fig. 148- A. — Points of maximum inten- 
sity and lines of transmission of aortic dias- 
tolic murmur. 



Fig. 148-5. — Points of maximum inten- 
sity and lines of transmission of aortic dias- 
tolic murmur. 



ciency. In such event there is a double murmur generated at the 
aortic valve, which is harsh during systole, and less harsh or 
actually blowing and musical during diastole. Such a double 
murmur is apt to be confused during a casual examination with 
a pericardial friction sound with its to-and-fro rhythm. 



TRICUSPID MURMURS 

Murmurs at the tricuspid area are infrequent ; but when they are 
present, they are either presystolic or systolic in time. 



388 



PHYSICAL DIAGNOSIS 



Tricuspid Presystolic Murmur.— A presystolic murmur arising 
at the tricuspid valve is indicative of tricuspid stenosis. The 
lesion is usually a congenital condition, as this murmur is very 
rarely encountered in an acquired form. 

The murmur is best appreciated at the tricuspid area over the 
lower portion of the sternum, whence it is not transmitted. In 
quality, time, and intensity it is the counterpart of the murmur of 
mitral stenosis. The murmur is usually associated with a thrill 
over the tricuspid area together with an enfeebled pulmonic 
second sound, and as a rule is attended by a variable degree of 
dyspnea and occasionally cyanosis. 




Fig. 149-A. — Point of maximum intensity of 
tricuspid presjstolic murmur. 



Fig. 149-B. — Point of maximum intensity of 
tricuspid presystolic murmur. 



Tricuspid Systolic Murmur. — A systolic murmur arising at the 
tricuspid area is indicative of tricuspid regurgitation. The caus- 
ative lesion may be a deformity of the cusps of the valve as a se- 
quence of ulcerative endocarditis ; but more commonly a systolic 
murmur at this valve is relative, the result of increased blood pres- 
sure in the right ventricle and pulmonary circulation as a result 
of an obstructive disease of the lung or of mitral insufficiency. 

This murmur is most clearly audible at the tricuspid area, 
whence it is transmitted upward and toward the right. It cor- 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



389 



responds to the systole of the ventricle, replacing- or masking the 
first sound of the heart at the tricuspid area. It is a soft, blow- 
ing murmur of moderate intensity. The murmur is accompanied 
by systolic pulsation in the jugular veins and frequently by sys- 
tolic pulsation of the liver. 

PULMONARY MURMURS 

Murmurs at the pulmonary area are of very frequent oc- 
currence, but organic disease of this valve is very rare. Most 




Fig. 150-A. — Point of maximum inten- Fig. 150-B. — Point of maximum inten- 

sity and line of transmission of tricuspid sity and line of transmission of tricuspid 
systolic murmur. systolic murmur. 



of these murmurs are functional, and Avill be discussed in a sub- 
sequent section. The murmurs generated at the pulmonic valve 
are invariably systolic or diastolic in time. 

Systolic Pulmonic Murmur. — A systolic murmur at the pul- 
monary valve is rarely encountered as an evidence of organic 
change in the valve and Avhen it is present it is usually a sign of 
pulmonary stenosis from a congenital lesion. The murmur oc- 
curs during ventricular systole ; it has its point of maximum 
intensity over the pulmonic area in the second left interspace ad- 



390 



PHYSICAL DIAGNOSIS 



jacent to the sternal border; it is harsh and unmusical; and it is 
transmitted upward toward the root of the neck. 

Diastolic Pulmonic Murmur.- — A diastolic murmur at this valve 
represents pulmonary regurgitation, due to alteration in the in- 
tegrity of the cusps of the valve incident to ulcerative endo- 
carditis or as a result of stretching of the orifice so that the 
normal cusps cannot close the opening (relative insufficiency). 

The point of maxium intensity of the murmur is localized in 
the pulmonary area, whence the murmur is propagated down- 
ward along the left sternal border. The murmur occurs during 
ventricular diastole, masking or replacing the second sound at 





Fig. 151-^ — Point of maximum inten- 
sity and line of transmission of pulmonary 
systolic murmur. 



Fig. 151-B. — Point of maximum inten- 
sity and line of tran;5mission of pulmonary 
systolic murmur. 



the pulmonic area. The murmur in quality resembles the murmur 
of aortic regurgitation in that it is not unmusical but is soft and 
blowing. 



FUNCTIONAL MURMURS 

Functional murmurs, which are also termed inorganic, acci- 
dental, and hemic murmurs, are endocardial murmurs which 
arise in a heart which is not the seat of permanent structural 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



391 



change. Functional murmurs are not caused by valvular de- 
formity; but they are due to excessive fluidity of the blood inci- 
dent to anemia, to temporary myocardial weakness during the 
course of acute fevers, to cardiac neuroses, or to stretching of 
the valvular orifices as a result of excessive physical effort. Func- 
tional murmurs are audible most frequently at the pulmonic area, 
and least frequently at the aortic area. They are more commonly 
encountered at the mitral than at the tricuspid area. 

Functional murmurs are transient, coming and going, but not 
persisting for any considerable length of time. They are always 
systolic, and are not transmitted beyond the precordia. They are 




Fig. 152-A. — Point of maximum inten- 
sity and line of transmission of pulmonary 
diastolic murmur. 



Fig. 152-B. — Point of maximum inten- 
sity and line of transmission of pulmonary 
diastolic murmur. 



encountered most frequently in association with states of anemia 
and asthenia. Functional murmurs are soft and of low pitch ; 
and when due to anemia, they are often accompanied by the hum- 
ming-top murmur in the jugular veins. 



MULTIPLE MURMURS AND THEIR DIAGNOSIS 

While the organic and functional murmurs arising at the vari- 
ous valves and orifices of the heart are separate entities and have 



392 PHYSICAL DIAGNOSIS 

been described singly, it is to be borne in mind that two or more 
murmurs may coexist in the same subject, the differentiation of 
Avhich is not infrequently attended with difficulty. 

When two distinct murmurs are encountered at two valve 
areas, as for instance at the aortic and the mitral areas, the mere 
presence of two murmurs at two valves does not necessarily sig- 
nify organic disease of both valves, as one murmur may be rela- 
tive on account of the dilatation of the left ventricle as the result 
of the aortic lesion. The mitral murmur in this instance is rela- 
tive and the aortic murmur is organic. Similarly, in organic 
mitral insufficiency there is not infrequently an associated rela- 
tive tricuspid regurgitation. 

An accurate diagnosis of multiple murmurs is often attended 
with great difficulty. When two murmurs occur at two phases of 
the cardiac cycle, one systolic and the other diastolic, this fact 
is of considerable assistance in the differentiation. When, how- 
ever two murmurs occurring at the same period of the cardiac 
cycle are discovered, the differentiation must rest largely upon 
the point of maximum intensity and the lines of transmission of 
the murmurs. The quality of the murmurs in this instance is of 
some assistance, remembering the general rule that stenotic mur- 
murs are harsh and unmusical, while regurgitant murmurs are 
generally soft, blowing, or musical. If, in the case of two mur- 
murs the one be harsh and the other soft and musical, there are cer- 
tainly two murmurs. If, on the contrary, both are alike in quality, 
it is possible that there is only one murmur, which is trans- 
mitted from the orifice where it is generated to a second orifice, 
as in the case of the transmission of the murmur of aortic insuf- 
ficiency to the apical area of the heart. 

Moreover, murmurs arising in the heart must be differentiated 
from a possible cardiorespiratory murmur by directing the pa- 
tient to suspend respiration, whereupon the latter will disappear. 
Finally, in the differentiation of multiple murmurs the ausculta- 
tory findings must be correlated with the general appearance of 
the patient and such accessory signs as edema, dyspnea and 
cyanosis. 

CARDIORESPIRATORY MURMUR 

The cardiorespiratory murmur is a systolic blow or whiff which 
is audible in the mitral area over the cardiac apex, closely simu- 
lating an endocardial murmur. The sound is produced by the 
impulse of the heart against a portion of lung which is anchored 



AUSCULTATION IN CARDIOVASCULAR DISEASE 393 

in front of the heart by pleural adhesions or hypertrophic em- 
physema. The sudden explusion of air from the portion of the 
lung by the impact of the heart generates a sound which closely 
simulates in many cases an endocardial murmur. 

PERICARDIAL FRICTION 

During inflammation of the pericardium the surfaces of the 
visceral and parietal membranes, which glide noiselessly over 
each other in health, become roughened and a friction sound is 
generated, which in certain instances closely simulates an endo- 
cardial murmur. The pericardial friction sound has a to-and-fro 
rhythm which is dependent upon the contractions of the heart, and 
which is not precisely synchronous with the heart sounds as are 
endocardial murmurs, but the phases of the pericardial friction 
sound last longer than do the heart sounds. The sound is variable, 
being exaggerated by moderate pressure with the stethoscope and 
being abolished in many cases by firm pressure with this instru- 
ment. Moreover, the sound is very transient, perhaps present at 
one examination and absent at subsequent examinations. The 
sound is altered by change of posture, often disappearing when 
the patient assumes the dorsal decubitus, to reappear upon his 
return to the erect posture. 

The pericardial friction sound is as a rule audible over the 
entire precordia, but it is most intense in the fourth and fifth 
interspaces to the left of the sternum. The two phases of the sound 
are of equal intensity, but of unequal duration. The sound seems 
very superficial, and it is not abolished upon suspension of res- 
piration as is the pleural friction sound. 

In pericarditis with effusion, as the fluid accumulates in the 
pericardial sac, the friction sound usually disappears, though it 
is not uncommon for it to persist at the base of the heart at the 
height of the effusion. 

PERICARDIAL SUCCUSSION SOUND 

Splashing or succussion sounds arising within the pericardium 
indicate the presence of air and fluid, or hydro-pneumo-pericar- 
dium. The sounds may be splashing, bubbling, or gurgling, and 
have been aptly compared to the sound which is produced by a 
water-wheel in motion. They are not abolished during suspension 
of respiration. 



394 PHYSICAL DIAGNOSIS 

VASCULAR MURMURS 

As endocardial murmurs are generated by deformities of the 
orifices of the heart and by changes in the fluidity of the blood, 
so also under somewhat similar circumstances murmurs are gen- 
erated in the arteries and veins. 

ARTERIAL MURMURS 

Auscultation may reveal the presence of murmurs in the aorta, 
the carotid, subclavian, brachial, and femoral arteries. In aus- 
cultation of an artery the examiner should apply the stethoscope 
over the vessel lightly but firmly, yet without exerting sufficient 
pressure to diminish the lumen of the vessel. He should then 
gradually apply sufficient pressure to partially occlude the ves- 
sel. During the first maneuver vascular phenomena may or may 
not be elicited. In the second examination even in a normal 
artery a systolic murmur is generated by the partial occlusion of 
the vessel. This murmur is produced by vibrations caused by 
fluid veins which are initiated by the vibrations set up by the pas- 
sage of the blood through the constricted portion of the vessel 
into the wider portion beyond. 

The Aorta. — Upon auscultation of the aorta in the left inter-" 
scapular region a systolic murmur in the vessel is a sign of aneu- 
rysm of the aorta. The murmur is accompanied by concomitant 
signs of aneurysm ; namely, dullness on percussion, frequently 
a palpable thrill, pulsation of the chest wall in many instances, 
and various pressure symptoms. Frequently there is tracheal 
tugging, or Oliver's sign. 

The Carotids. — Upon auscultation of the carotid artery the first 
and second sounds of the heart may sometimes be heard, although 
the first sound is more frequently inaudible. These sounds are 
not to be confounded with murmurs; they are merely the normal 
sounds of the heart which are transmitted along the course of the 
blood column. Endocardiac murmurs, however, are similarly 
transmitted, a harsh systolic murmur audible over the vessel sig- 
nifying aortic stenosis, aortic roughening, or aneurysm of the 
arch. The transmitted second sound of the heart may be replaced 
by the diastolic murmur of aortic regurgitation. 

The Subclavian Artery. — In certain cases of apical pulmonary 
tuberculosis a systolic murmur is audible in the subclavian artery. 
The murmur in this instance is due to constriction or to bending 
of the lumen of the vessel by the traction of pleural adhesions. 



AUSCULTATION IN CARDIOVASCULAR DISEASE 395 

A diastolic murmur is occasionally audible in the subclavian 
artery in aortic regurgitation, or Corrigan's disease. 

The Femoral Artery. — In many cases of aortic regurgitation a 
double murmur, systolic and diastolic, may be elicited by auscul- 
tation over the femoral artery, the systolic murmur resulting 
from the sudden injection of blood into the aorta, and the dias- 
tolic murmur resulting from the reflux of the blood stream which 
the incompetent aortic valve is incapable of sustaining in the aorta. 
This double murmur in the femoral artery constitutes Duroziez's 
sign of aortic regurgitation, or Corrigan's disease. 

VENOUS MURMURS 

A continuous murmur may be elicited over the jugular vein in 
health by tightly applying the bell of the stethoscope to the in- 
tegument over the vein. A similar murmur may occasionally be 
generated by turning the head far to one side. Hence, in auscul- 
tation of this vessel the stethoscope should be lightly applied 
and the head should be maintained in a symmetrical position. 

The Venous Hum. — The principal diagnostic sign afforded by 
auscultation of the venous system is the venous hum, humming- 
top murmur y nun's murmur, or hruit de diable. This murmur, 
which is continuous, has been compared to the sound of the buz- 
zing of insects and to the sound of a circular saw in action, com- 
parisons which give but an imperfect conception of the quality 
of the sound. The sound is commonly elicited over both jugulars, 
but is more intense as a rule over the right vein. The murmur 
has its maximum intensity just at the inner third of the clavicle- 
Its intensity is greater when the patient sits upright, during 
inspiration, and during cardiac diastole, for reasons which are 
explained in a following paragraph. 

The bruit de diable is generated in the bulb of the jugular 
vein and not in the carotid artery, as Laennec believed. The 
intravenous generation of the murmur is demonstrated by the 
fact that the murmur is continuous and is not intermittent as 
are arterial bruits; and that it can be entirely suppressed by light 
compression upon the jugular vein, a pressure too insignificant 
to appreciably infiuence the action of the carotid circulation. 

The intensity of the bruit is influenced by the factors enumer- 
ated in a foregoing paragraph for the reason that these factors 
favor a more rapid flow of blood through the veins. During in- 
spiration and cardiac diastole the blood is aspirated from the 
large veins of the thorax, while during expiration and cardiac 



396 PHYSICAL DIAGNOSIS 

■ * 

systole the flow of blood from these veins is transiently arrested. 
The intensity of the murmnr is appreciably diminished upon ro- 
tation of the head toward the opposite side of the body, as a 
result of constriction of the jugular vein by the bands of the 
cervical fascia and the omohyoid muscle. 

It is likely that increased fluidity of the blood and malnutrition 
of the vascular walls with consequent relaxation play some part 
in the generation of the venous hum, as it is most constantly en- 
countered in subjects of chlorosis and pernicious anemia. 

Friedreich has detected a similar venous murmur in the right 
interscapular region at the level of the third and fourth dorsal 
vertebrae, which occurred in conjunction with the venous hum in 
the jugular vein, and which he attributed to fluidity of the venous 
content of the superior vena cava. 

BLOOD PRESSURE 

Definition. — It is obvious that for the maintenance of a con- 
stant flow of blood through the vessels a certain degree of force 
must be exerted upon the blood column. This force, which 
governs the onward course of the blood, constitutes blood pres- 
sure, and is derived from three principal sources. 

At each contraction of the left ventricle a variable quantity, 
from 80 to 100 c.c. of blood, is forced into the aorta. But this 
volume of blood is not injected into an empty vessel. The aorta 
is filled with blood at the commencement of ventricular systole, 
as not sufficient time elapses between the ventricular systoles 
for the blood to flow from the large arteries into the capillaries 
and veins. As a consequence, when the systolic discharge of 
blood from the ventricle occurs, the walls of the large arteries 
yield or are stretched by virtue of the elastic elements which 
they contain. As a result of this elasticity, the vascular walls 
immediately contract upon the contents of the vessels and force 
the blood column onward. 

However, the flow of the blood through the vessels encounters 
a distinct resistance to its onward progress, when the capillaries 
are reached, an obstacle to which the term ''peripheral resist- 
ance" is applied. When it is recalled that the sectional area of 
the capillaries is many hundreds of times as great as that of the 
larger arteries, it is obvious that a considerable degree of fric- 
tion is generated by the passage of the blood through these 
minute vessels. 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



397 



Moreover, the arterioles, the immediate precursors of the cap- 
illaries, are supplied with a special nervous mechanism through 
the vasomotor nervous system, whereby the calibre of these 
vessels may be constricted or dilated, thus producing variations 
in the degree of peripheral resistance. 

Thus, the term hlood pressure refers to the interaction of these 
three factors (ventricular contraction, elasticity of the arteries, 
and peripheral resistance), and clinically it represents the total 
pressure exerted by the heart and blood vessels. 

Determination of Blood Pressure. — Clinically it is desirable to 





Fig. 153. 



-Cook's modification of Riva-Rocci's blood pressure instrument. (From Warfield.) 



determine the blood pressure during ventricular systole (systolic 
pressure) ; during ventricular diastole (diastolic pressure) ; and 
the difference between these determinations, (pulse pressure). 

Blood pressure is determined by an instrument, the sphygmo- 
manometer, the procedure being termed sphygmomanometry. The 
first really accurate and practical sphygmomanometer was devised 
by Kiva-Rocci in 1896. This instrument has been modified by Cook, 
Stanton, Erlanger, Janeway, and Faught, the basis of all in- 
struments of this type consisting of an inflatable rubber bag, con- 
tained in an inelastic leather cuff so that during inflation of the 
bag the entire pressure is exerted upon the encased arm ; a mer- 
cury manometer ; and an air pump so connected by rubber tubing 



398 



PHYSICAL DIAGNOSIS 



that the air which is pumped is distributed with uniform pres- 
sure to the cuff and the manometer. 

A recently devised instrument, which dispenses with the use 
of the mercury manometer, and which instead of recording the 
pressure in millimeters of a mercury column records the pres- 
sure upon a dial, is the Rogers Tycos Instrument. 

With either type of instrument in recording the blood pres- 
sure tAYO methods may be employed; namely the palpatory 




Fig. 154. — Stanton's sphygmomanometer. (From Warfield.) 

method; or the auscultatory method. WhichcYcr method is em- 
ployed, certain details of the technic must be observed in order 
to obtain satisfactory results. The cuff should be placed at least 
two inches above the bend of the elbow; the connections of the 
tubing to the different portions of the instrument should be air- 
tight; the dilatable rubber bag should be adapted to the inner 
portion of the arm, overlying the brachial artery; the cuff should 
be snugly applied, but not with sufficient force to interfere with 
the venous return; and the lower portion of the cuff should fit the 
arm more loosely than the upper portion. 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



399 



Palpatory Method. — When the cuff has been properly fitted 
to the arm and the tubing to the recording instrument, manom- 
eter or dial, air is pumped into the cuff until the pulse becomes 




Fig. 155. — The I^rlanger sphygmomanometer with the Hirschfelder attachments by 
means of which simultaneous tracings can be obtained from the brachial, carotid, and 
venous pulses. (From Warfield.) 

inappreciable to the finger palpating the radial artery. When 
the pulse disappears the mercury is pumped up 10 or 15 mm. 
above this point; and the screw is turned which allows the mer- 
cury to drop very slowly. At the instant that the pulse be- 



400 



PHYSICAL DIAGNOSIS 




1 



Fig. 156. — The Janeway sphygmomanometei- which has been found a convenient and 
practicable instrument. The scale can be pushed below the level of the top of the box, 
the long arm of the mercury tube is disjointed and placed in the bottom of the box, 
the lid is then closed, and the instrument takes up but little space in the physician's bag. 
(From Warfield.) 



AUSCULTATION IN CARDIOVASCULAR DISEASE 401 

comes again appreciable at the wrist the release valve is closed 
and the systolic pressure is read upon the scale or dial. 

The principle involved in this procedure is that it requires an 
amount of external pressure to obliterate the pulse in the artery, 
which is commensurate with the intravascular pressure during; 
systole. 

Having determined the systolic pressure by the method de- 
scribed, the release valve is again slowly rotated, and the column 
or needle allowed to descend upon the scale very slowly, the undu- 
lations of the column or needle being closely observed. The de- 
scent is attended by oscillations ; and at one point in the descent 
these oscillations become very pronounced, this point correspond- 
ing to the diastolic pressure, and as a rule being accompanied by a 
larger pulse wave than normal at the wrist. 

By deducting the diastolic pressure from the systolic pressure, 
as recorded, the pulse pressure is obtained. In a healthy adult 
male the systolic blood pressure usually ranges between 120 and 
135 millimeters, though a systolic pressure of 140 in such a 
patient is not necessarily pathologic. The diastolic ranges be- 
tween 90 and 110 millimeters, the pulse pressure usually ranging 
from 25 to 35 millimeters. 

Auscultatory Method. — The auscultatory method of determin- 
ing the blood pressure is more accurate than is the palpatory 
method, and, in addition, shows wider ranges of pressure in the 
individual case. The systolic pressure, as determined by the 
auscultatory method, is always about 5 millimeters above that 
registered by the palpatory method, whereas the diastolic pres- 
sure often ranges 10 to 15 millimeters below that obtained by the 
palpatory method. 

In determining blood pressure by this method the bell of a 
stethoscope is applied over the brachial artery just above the 
bend of the elbow, and the cuff inflated until all sound disap- 
pears. Having attained this point, the air is allowed to slowly 
escape from the cuff, whereupon a series of sounds are heard 
which have been divided into five phases. The first phase is rep- 
resented by the first sound which is heard, which is the proper 
point at which to record the systolic pressure. The first phase is 
quickly followed by a peculiar murmuring sound as the tension in 
the cuff is lowered, the second phase; this in turn is followed by a 
sharp, ringing note of increased intensity, the third phase. The 
sharp murmur of the third phase gradually gives place to a less 
intense sound, the fourth phase; this phase lasts until all sound 



402 PHYSICAL DIAGNOSIS 

ceases, the fifth phase. The diastolic pressure may be recorded at 
the beginning of the fourth phase or at the beginning of the fifth 
phase, the time at Avhich all sound ceases. There is a difference 
of approximately 5 millimeters, as the record is made at the 
fourth or the fifth phase; but as it is often difficult to say just 
when the fourth phase begins, and as it is relatively easy to de- 
termine when all sound ceases, it is a safe rule to record the dias- 
tolic pressure at the commencement of the fifth phase, bearing 
in mind the discrepancy between the reading at the two phases. 
Normal Variations. — Before drawing conclusions from varia- 
tions in blood pressure, certain normal variations must be elim- 
inated. Thus, the pressure varies with the attitude assumed by 
the patient, being higher when he stands, and lower when the 
sitting or recumbent attitude is assumed. Clinically the blood 




Fig. 157. — Rogers' "Tycos" dial sphygmomanometer. (From Warfield.) 

pressure may be estimated with the patient either in the sitting 
or recumbent posture with equally satisfactory results; but which- 
ever attitude is assumed at the first estimation should be em- 
ployed in all subsequent examinations. After a full meal the 
blood pressure is slightly higher than it is several hours after a 
meal ; and during sleep it is normally lower than during waking 
hours. Exercise, nervous excitement, and the ingestion of stimu- 
lants increases the blood pressure temporarily. Similarly, high 
altitudes raise the blood pressure temporarily. 

Pathologic Variations. — When a high systolic pressure is 
encountered in a patient who is and has been at rest, it usually 
points to cardiac hypertrophy, the causes of which are varied ; to 
arteriosclerosis, to nephritis, or brain tumor, or apoplexy. In 
female subjects, it may point to threatened eclampsia. In car- 
diovascular disease a high systolic pressure which is accom- 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



403 



panied by an increased pulse pressure usually is indicative of 
adequate compensation; whereas a normal systolic pressure with 
a decreased pulse pressure points to threatened cardiac failure. 

A decrease in the systolic pressure accompanies conditions of 
shock and collapse, internal hemorrhage, and the vascular asthe- 
nia of Addison's disease. In the course of typhoid fever a sud- 
den drop in the systolic pressure is suggestive of perforation. 
A low systolic pressure is often an early sign of phthisis. 

The importance of variations in the diastolic pressure has come 
to be generally recognized. The diastolic pressure represents the 





Fig. 158. — A. The Faught blood pressure instrument. An excellent instrument which 
is quite easily carried about and is not easily broken. (From Warfield.) B. Detail of the 
dial in the "Tycos" instrument. (From Warfield.) 

degree of peripheral resistance which must be overcome before 
the left ventricle may discharge its contents; and if this pres- 
sure is raised, as it usually is in arterial fibrosis and chronic 
interstitial nephritis, an added burden is thrown upon the heart 
before the blood can begin to circulate. Moreover, when a high 
diastolic pressure is encountered, it is of great importance from 
the standpoint of prognosis and treatment to determine whether 
this increase is due to functional angiospasm or to organic disease 
of the arterial system. In aortic regurgitation the diastolic pres- 
sure is low, while the pulse pressure is increased to a correspond- 
ing degree. 



404 



PHYSICAL DIAGNOSIS 



The pulse pressure deserves careful study *in all cases in which 
sphygmomanometry is practiced. The pulse pressure represents 
the contractile power of the left ventricle in excess of the diastolic 




Fig. 159. — Method of taking blood pressure with a patient in sitting position. (From 

Warfleld.) 




jgasrf 



Fig. 160. — Method of taking blood pressure with patient lying down. (From Warfield.) 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



405 



pressure ; or, in other words, the power of the left ventricle over 
and above the peripheral resistance to the circulation of the 
blood. Thus, in the course of lobar pneumonia, when the heart 
is laboring under an increased load, a daily record of the pulse 
pressure gives valuable information as to the state of the myocar- 
dium, and affords a valuable prognostic and therapeutic index. 
As the overtaxed heart gradually fails, the systolic pressure 
gradually approximates the diastolic pressure, the pulse pres- 
sure steadily diminishing until it is nil, the point at which life 
becomes impossible. 




Fig. 161. — Observation by the auscultatory method and a mercury instrument. One hand 
regulates the stopcock which releases air gradually. (From Warfield.) 



Venous Pressure. — Hooker, who has devised an apparatus 
which permits the recording of the venous pressure, states that 
there is a progressive rise of venous pressure from youth until 
old age. He also finds that just before death there is a rapid 
rise of the venous pressure. Clark* states that a venous pressure 
of 20 centimeters of water represents the limit between adequate 
compensation and decompensation of the heart, and that a rise 
above this point is apt to be followed by cardiac failure. 

A rough estimate of the venous pressure may be made by ob- 
serving the superficial veins upon the back of the hand when the 



*Arch. Int. Med., Oct., 1915. 



406 PHYSICAL DIAGNOSIS 

hand is raised above the level of the heart. 'Normally these veins 
should collapse when the hand is raised above the level of the 
heart, and they should practically collapse with the hand at the 
level of the cardiac apex. But in the presence of increased 
venous pressure the veins fail to collapse when the hand is 
raised even above the level of the heart. Oliver states that the 
venous pressure may be estimated in millimeters of mercury by 
multiplying by 2 each inch above the level of the cardiac apex in 
which the veins collapse. 






SECTION V 

DISEASES OF THE CIRCULATORY ORGANS 

CHAPTER XVII 

DISEASES OF THE PERICARDIUM 

PERICARDITIS 

Inflammation of the pericardium occurs primarily and as a 
secondary disease. Primary pericarditis has followed trauma to 
the pericardium from external violence. Certain cases of primary 
so-called idiopathic pericarditis develop in children without as- 
signable cause. 

Secondary pericarditis occurs as a sequence of acute rheumatic 
fever, acute tonsillitis and other septic states, as also in gout, 
tuberculosis, and during the course of general arteriosclerosis. 

Pericarditis occurs in three principal forms ; namely, acute 
fibrinous pericarditis; serofibrinous pericarditis, or pericarditis 
with effusion; and chronic adhesive pericarditis. 

ACUTE FIBRINOUS PERICARDITIS (PERICARDITIS 

SICCA) 

Clinical Pathology. — In this form of pericarditis, which is also 
termed pericarditis sicca, the surface of the visceral pericardium, 
and later during the evolution of the disease that of the parietal peri- 
cardium as well loses its normal smooth, glistening appearance 
and becomes roughened. It is the seat of a fibrinous exudate, 
which may be circumscribed to a small portion of the membrane, 
or which may be universal, involving the entire pericardial sur- 
face. There is usually slight effusion into the pericardial sac, 
but in cases of tuberculous origin it is distinctly a dry inflamma- 
tion. The roughened, exudate-clothed pericardium does not glide 
noiselessly as is the case during health, but in lieu of this it is 
accompanied by a friction rub. 

The gross appearance of the pericardial surface varies in differ- 
ent stages of the disease. In the incipiency of the disease the 
surfaces present the appearance of two slices of bread and butter 

407 



408 



PHYSICAL DIAGNOSIS 



which have been apposed and pulled asunder, the ''bread and 
butter" stage of the disease. In other instances the exudate is 
rolled into irregular folds upon the pericardial surface, constitut- 
ing the ''cor villosum. " 

The subjacent myocardium is involved to a variable extent in 
the inflammatory process, presenting infiltration with leucocytes, 
and endocarditis is occasionally a coincident disease. 

Physical Signs. — Inspection. — In acute fibrinous pericarditis in- 
spection usually reveals few signs, though it is not uncommon for 
the respirations to be accelerated, indeed occasionally to the point 




Fig. 162. — Acute fibrinous pericarditis. (From McFarland.) 



of orthopnea. The cardiac impulse is accentuated in force, and 
frequently its area is extended. The facial expression is apt to be 
anxious. 

Palpation in the fully established cases frequently reveals the 
presence of pericardial friction fremitus over the precordia, which 
is increased in intensity when the patient bends the trunk forward. 
The pulse is accelerated, but is usually of normal volume and 
tension. 

Percussion reveals no deviation from the normal outline of the 
heart, as the organ is not enlarged in uncomplicated acute fibrinous 
pericarditis. 



DISEASES OF THE PERICARDIUM 409 

Auscultation elicits the pericardial friction sound over the pre- 
cordia. This sound is variable ; it is increased by moderate pressure ^ 
and is abolished by strong pressure with the bell of the stethoscope ; 
it also varies in intensity upon change of posture ; and it varies in 
intensity from day to day without apparent cause. The sound 
corresponds roughly with the sounds of the heart, but not with the 
same accuracy as do endocardial murmurs, as the phases of the 
friction sound last longer than do the heart sounds. The friction 
sound usually presents two phases, systolic and diastolic, occasion- 
ally only a single phase, and in yet other instances three phases, 
simulating canter-rhythm or gallop-rhythm. When the sound pre- 
sents the typical systolic and diastolic phases, these phases exhibit 
the same intensity, but are usually of unequal length. The peri- 
cardial friction sound is confined strictly to the jjrecordia and is not 
transmitted thence, as are endocardial murmurs. If the associated 
effusion becomes great, the friction sound disappears, but not 
infrequently it remains audible over the base of the heart even at 
the height of the effusion. The sound is usually heard with the 
greatest ease along the left border of the sternum in the fourth and 
fifth interspaces, or near the aortic valve area. In certain instances, 
however, the sound is most clearly audible over the cardiac apex. 
The pericardial friction sound seems very superficial, as if it were 
just beneath the ear. 

Diagnosis. — The diagnosis of acute fibrinous pericarditis is 
readily made when the disease is suspected and the fricti^rrf 
sound, the pathognomonic sign of the disease, is detected. But, 
arising as it so frequently does during the course of an acute 
infectious disease, it is often masked by the other symptoms of 
the disease and is not suspected or sought for and hence is fre- 
quently overlooked. 

Differential Diagnosis. — A mistake in diagnosis may arise in 
failing to differentiate acute fibrinous pericarditis from organic ^ 
disease of the aortic valve, or from pleuropericardial friction in 
pleurisy arising during pneumonia or pulmonary tuberculosis. 
Organic disease of the aortic valve produces a double murmur, 
systolic and diastolic in time, with a palpable thrill, which may be 
easily mistaken for the two phases of the pericardial friction 
sound. But this double murmur corresponds very closely indeed 
with the events of the cardiac cycle ; the murmurs are transmitted 
from the precordia in different and definite lines ; and the disease 
produces alterations in the character of the pulse, as for instance 
the water-hammer pulse in Corrigan's disease, and the small wiry 



410 PHYSICAL DIAGNOSIS 

pulse of aortic stenosis. The close circumscription of the maxi- 
mum intensity of the murmur to the aortic orifice is of aid in 
differentiation; and, moreover, aortic disease causes hypertrophy 
of the heart with alteration in the cardiac outline. The peri- 
cardial friction sound is more superficial and variable than is the 
aortic murmur, and is infiuenced by pressure with the bell of the 
stethoscope, which does not influence the murmur of organic dis- 
ease of the aortic valve. 

The pleuropericardial friction sound resembles in some respects 
the pericardial friction sound, but it disappears during suspen- 
sion of respiration following full inspiration. 

Acute fibrinous pericarditis is accompanied by pain over the 
precordia or around the xyphoid appendix, and by moderate 
fever. 

SEROFIBRINOUS PERICARDITIS (PERICARDITIS WITH 
EFFUSION; PERICARDITIS EXUDATIVA) 

Clinical Pathology. — Serofibrinous pericarditis, pericarditis 
with effusion, or pericarditis exudativa has its inception as a dry 
plastic pericardial inflammation, during which stage of the dis- 
ease the pericardial surface is clothed with fibrinous exudate. In 
the further evolution of the disease there is effusion of serofibrin- 
ous fluid, which fills the dependent portions of the pericardial 
sac. The fiuid is frequently turbid, containing flocculi of flbrin. 
The quantity of the fluid varies from a few ounces to two liters 
or even more in the extreme case. 

Unless aspirated, the natural tendency is toward absorption of 
the fluid, occasionally with no permanent damage to the peri- 
cardium; but in other instances with the formation of adhesions 
between the visceral and parietal layers of the membrane ; and 
in yet other instances with localized areas of pericardial thick- 
ening, the so-called ''milk spots," or ''soldier spots" of this 
disease. 

The subjacent myocardium is inflamed to a variable degree, and 
endocarditis is occasionally a concomitant condition. 

Physical Signs. — Inspection. — Seroflbrinous pericarditis is at- 
tended by a variable degree of precordial bulging, particularly when 
the disease develops during childhood, when the chest wall is very 
resilient, and in the female subject with thin thoracic parietes. 
The rigid chest wall of the adult male does not invariably yield to 
the local increase of intrathoracic tension. However, in the pres- 



DISEASES OF THE PERICARDIUM 411 

ence of extensive effusion into the pericardium there is visible 
epigastricjbulging in the vast majority of cases, constituting Auen- 
brugger's sign of the disease. In a fully established effusion the 
cardiac impulse is not infrequently invisible ; or, when it is visible, 
the impulse is commonly displaced upward, presenting a wavy 
pulsation in the third or fourth intercostal space. When the apex 
beat is invisible with the patient in the recumbent or sitting pos- 
ture, it may in certain instances become again visible when the 
patient bends the trunk forward. 

The respirations are moderately accelerated, and in extensive 
pericardial effusion they are frequently attended by dyspnea which 
occasionally amounts to orthopnea. The left half of the thorax is 
apt to expand in a deficient fashion, as a result of compression of 
the left lung by a large effusion. Earely, indeed, does the examiner 
encounter tortuosity of the superficial veins of the thorax as a 
result of increased intrathoracic tension. 

Palpation. — Palpation confirms the displacement of the cardiac 
impulse. Early in the disease a friction fremitus is palpable, 
which disappears as the effusion develops, though' it sometimes 
persists at the base, to reappear with absorption of the effusion. 
As to intensity, the cardiac impulse is f eeble, . and gradually de- 
creases in intensit}^ as the effusion develops, to eventually disappear 
altogether. Ewart has noted that the first' rib is freely palpable at 
its chondrosternal articulation in pericarditis with effusion, the 
''first rib sign." Fluctuation can be obtained only in the presence 
of very large effusions and is not to be expected in other cases. 
Frequently there is moderate tenderness upon palpation of the 
epigastrium. 

The pulse in serofibrinous pericarditis is usually weak and of 
small volume, often irregular, and of the pulsus paradoxus type, 
becoming progressively more feeble during full inspiration.* 

Percussion. — The area of cardiac dullness is extended, and this 
increases progressively as the effusion develops. The area of dull- 
ness is roughly pear-shaped, with the base directed downward 
toward the diaphragm. In the fifth intercostal space the dullness 
extends one or two inches to the right of the sternum, obscuring the 
normal pulmonary resonance in Ebstein's cardiohepatic angle, 
constituting Rotch's sign of the disease. Upon the left side the 
dullness of the heart is apt to extend outward beyond the apex or 
even to encroach upon and obscure the normal gastric tympany in 
Traube's semilunar space. The diaphragm and the left lobe of the 
liver are depressed by the weight of the effusion. Gerhardt pointed 



412 PHYSICAL DIAGNOSIS 

out that when the patient is in the upright posture the area of dull- 
ness is broader than when he is in the recumbent posture. A coexist- 
ing hypertrophic emphysema may serve to obscure the dullness of a 
fairly large pericardial effusion by the interposition of the volum- 
inous anterior pulmonary borders between the pericardium and the 
anterior wall of the thorax. 

Percussion of the left side of the thorax posteriorly, near the 
angle of the scapula, with the patient in the upright posture, in 
the presence of extensive pericardial effusion not infrequently 
yields dullness, which disappears when the patient inclines the 
trunk forward, Bamberger's sign of the disease. 

Auscultation. — During the incipient stage of the disease, prior 
to the development of the effusion, a pericardial friction sound is 
audible over the precordia. When the effusion develops this fric- 
tion rub disappears gradually, although frequently persisting at 
the base of the heart. If inaudible when the patient is in the re- 
cumbent posture, it occasionally appears when he is placed in the 
sitting posture. The cardiac sounds become gradually weakened 
and muffled as the effusion develops. The pulmonic second sound 
is apt to be accentuated. The compression of the left lung in ex- 
tensive pericardial effusion is apt to result in bronchovesicular or 
bronchial breath sounds in the axillary region. 

Diagnosis. — The pear-shaped area of increased cardiac dullness, 
the initial friction sound, which disappears with the development 
of the effusion, the muffled and distant character of the cardiac 
sounds, with pain over the precordia, Avhich is aggravated by 
pressure over the lower end of the sternum, dyspnea, occasionally 
cyanosis, the paradoxical pulse, and fever, point strongly to effu- 
sion into the pericardium. 

Differential Diagnosis. — Dilatat ion of the he art produces in- 
crease in the area of the heart, but in this disease there are suffi- 
cient differential signs to distinguish the two conditions. In 
cardiac dilatation the cardiac impulse instead of being obscured 
is distinctly visible and wavy; the shock of the cardiac valves is 
distinctly palpable in dilatation; the area of cardiac dullness in 
dilatation is not pear-shaped, neither does it, except in the case 
of mitral stenosis, reach so high along the left sternal margin or 
so low in the fifth and sixth interspaces without visible or pal- 
pable impulse ; rarely indeed is the enlargement of the heart in 
dilatation so large as to compress the left lung with the produc- 
tion of dullness and bronchovesicular or bronchial breath sounds 
over the left lung; in dilatation the cardiac sounds are distinctly 



DISEASES OF THE PERICARDIUM 413 

audible, frequently with a valvular quality engrafted upon them; 
and the fluoroscopic findings are entirely different in the two 
diseases. 

Serofibrinous pleurisy occasionally must be differentiated from 
pericarditis with effusion when the effusion reaches an extreme 
grade. In left-sided pleural effusion, unless the effusion assumes 
the encysted form, it is likely during a casual examination to be 
mistaken for a large pericardial effusion ; and similarly a large 
pericardial effusion may be difficult to differentiate from effusion 
into the left pleural sac. But in pleurisy with effusion the cardiac / 
impulse is displaced; the flatness extends around the side of the 
thorax ; the compressed lung yields Skodaic resonance in the infra- 
clavicular and mammary regions; Traube's ^milunar space of 
gastric tympany is obliterated; and the spleen is apt to be dis- 
placed downward. In serofibrinous pericarditis, on the contrary, 
the effusion is apt to extend well to the right of the sternum 
(Rotch's sign), which is of aid in the differentiation of the two 
diseases. 

CHRONIC ADHESIVE PERICARDITIS 

Clinical Pathology. — In chronic adhesive pericarditis adhesions 
are formed as the consequence of a previous acute pericarditis of 
the fibrinous or serofibrinous form. In many instances the adhe- 
sions are sparsely distributed or are localized to a limited area 
of the visceral and parietal membranes, while in other cases they 
are more or less universally distributed over these membranes. 
Moreover, the adhesions may exist between the external surface 
of the pericardium and the adjacent pleura, constituting pleuro- 
pericarditis or mediastinopericarditis. 

The internal form of chronic adhesive pericarditis, in which the 
adhesions exist between the visceral and parietal layers of the 
membrane, often does not lead to embarrassment of the cardiac 
action, and frequently gives rise to no symptoms and few physi- 
cal signs. But when the adhesions are abundant there is a 
variable degree of cardiac embarrassment, with consequent hyper- 
trophy of the heart. 

In external chronic adhesive pericarditis adhesions bind the 
outer surface of the pericardial sac to the costal pleura anteriorly 
or to the diaphragm, or to the esophagus or spinal column, or to 
the great vessels arising from the base of the heart. In this form 
of the disease the contraction of the ventricles not infrequently 
produces systolic retraction of the thoracic wall ; or the constrict- 



414 



PHYSICAL DIAGNOSIS 



ing bands may result in dysphagia, stridulous respiration, or vas- 
cular murmurs. 

The coincident changes in the myocardium in chronic adhesive 
pericarditis vary with the degree of interference with the heart's 
action. Frequently it is entirely unaltered in the presence of 
simple adhesions within the pericardial sac ; while it presents 
hypertrophy and occasionally thinning and dilatation of the walls 
of the cardiac chambers in the presence of extensive adhesions. 

Physical Signs. — Inspection. — In cases which are associated with 
cardiac hypertrophy there is apt to be moderate precordial bulging, 
with displacement of the cardiac impulse from its normal site in 
the fifth left intercostal space. There is frequently systolic re- 




^i&i 



Fig. 163. — Pericardial adhesions. (Prom Delafield and Prudden.) 

traction of the chest wall anteriorly near the apical area. In cases 
with diaphragmatic- adhesions there is often a systolic retraction 
of the tenth and eleventh interspaces posteriorly below the left 
scapula (Broadbent's sign). 

Friedreich's sign, diastolic collapse of the jugular veins is noted 
frequently; and Kussmaul's sign, inspiratory overfullness of the 
jugulars is occasionally in evidence. The diaphragmatic shadow 
is frequently restricted or abolished by partial immobilization of the 
diaphragm by adhesions. The apex-beat, in addition to the dis- 
placements to which it is so frequently subject in this disease, does 
not exhibit its normal range of lateral mobility upon placing the 
patient in the lateral decubitus. 



i 



DISEASES OF THE PERICARDIUM 415 

Palpation. — In chronic adhesive pericarditis there is not infre- 
quently demonstrable upon palpation of the precordia a distinct 
diastolic ishock, which is due to the sudden rebound of the heart 
walls during diastole, which have been drawn into apposition 
during systole increasing the tension which is exerted by the ad- 
hesions. .Palpation is useful in defining the displacement of the 
cardiac impulse. Adhesions between the pericardium and dia- 
phragm frequently inhibit the normal epigastric excursion during 
inspiration. The mil^e is of the pulsus paradoxus type in many 
cases, trailing off during full inspiration. 

Percussion. — As a rule, percussion reveals a considerable increase 
in the transverse diameter of the area of cardiac dullness ; but this 
is not constant, as in certain cases the heart is neither hypertrophied 
nor dilated. Occasionally the superior and left borders of the area 
of cardiac dullness are not diminished at the completion of full 
inspiration, because adhesions between the pleura and the peri- 
cardium prevent the intervention of the anterior border of the left 
lung between the heart and the anterior chest wall during inspira- 
tion. Not infrequently the gastric tympany of Traube's semilunar 
space is diminished. 

Auscultation. — The character of the heart sounds varies with the 
state of the myocardium. In the presence of coincident cardiac 
hypertrophy they are accentuated; whereas, if cardiac dilatation 
has supervened, they are muffled and more or less valvular : Mur- 
murs of coexisting valvular disease are occasionally audible, which 
are not dependent upon the disease for their production. Occa- 
sionally a pericardiaLfxict ion sound is audible along the left sternal 
border. Reduplication of the second sound of^the heart is occa- 
sionally audible, and sometimes there is a soft blowings systolic 
murmur at the mitral area. 

Diag'nosis. — With a history of previous pericarditis, the finding 
of signs of pericardial adhesions, such as fixation of the cardiac 
impulse, inspiratory overfullness of the jugular veins and diastolic 
collapse of these vessels, with systolic retraction of the thoracic 
wall anteriorly, or Broadbent's sign posteriorly, is suggestive of 
chronic adhesive pericarditis. While it is true that a systolic 
retraction of the chest wall in the region of the cardiac apex may 
be due to atmospheric pressure in the presence of cardiac hyper- 
trophy, when the anterior borders of the lungs are tardy in 
closing the interval between the heart and the anterior chest 
wall, the systolic retraction of chronic adhesive pericarditis is 
altogether more forcible than is this phenomenon. 



416 PHYSICAL DIAGNOSIS 

■ * 

In cases in Avhich only a limited number of adhesions exist 
between the epicardinm and the visceral pericardium, causing 
little or no embarrassment of the action of the heart, a diagnosis 
is extremely difficult. 

HYDROPERICARDIUM (HYDROPS PERICARDII) 

Clinical Pathology. — Hydropericardium, the presence of serous 
fluid in the pericardiac sac, is usually a sequence of the general 
anasarca of nephritis or of valvular heart disease. In rarer in- 
stances such a serous transudation is the sequence of thrombosis 
of the cardiac veins. In hydropericardium the pericardial sac 
contains a variable amount of clear, serous, noninflammatory 
fluid. 

Physical Signs. — The physical signs of hydropericardium are 
essentially those of fluid in the pericardial sac. There is, how- 
ever, absence of the friction sound, pain, and fever, which serves 
to exclude seroflbrinous pericarditis. Coupled with a history of 
cardiac or renal disease, the physical signs point toward hydro- 
pericardium, though in many instances the transudation of fluid 
is but moderate in degree and the condition is entirely overlooked. 

HEMOPERICARDIUM 

Clinical Pathology. — The accumulation of blood or sanguineous 
fluid in the pericardial sac occasionally follows stab wounds or 
penetrating wounds of the pericardium from other causes. It 
may be due to rupture of the ascending portion of the aorta, 
which is enveloped by the pericardium, in which event the disease 
is rapidly fatal, or it may follow rupture of a coronary artery. 
Occasionally the fluid of serofibrinous pericarditis is tinged with 
blood. 

Physical Signs. — The physical signs of hemopericardium are 
those of effusion into the pericardium. Added to these signs in 
certain cases are signs of internal hemorrhage, as pallor, rapid 
Aveak pulse, dyspnea, and collapse. In grave cases death ensues 
early from pressure upon the heart. 

PNEUMOPERICARDIUM (HYDRO-, HEMO-, OR PYO- 
PNEUMOPERICARDIUM) 

Clinical Pathology. — Pneumopericardium, the presence of gas 
in the pericardial sac, is usually associated with the presence of 



DISEASES OF THE PERICARDIUM 417 

serous fluid (hydro-pneumopericardium), blood (hemo-pueumo- 
pericardium), or pus (pyo-pneumopericardium). The disease is 
but rarely encountered. 

Pneumopericardium may result from penetrating wounds of 
the pericardium; from perforation of the pericardium by a tuber- 
culous cavity of the lung, gangrene of the lung, or pneumothorax ; 
or it may be spontaneous, owing to the development of the bacil- 
lus aerogenes capsulatus of Welch. Malignant disease of the 
esophagus or stomach very rarely causes perforation of the peri- 
cardium and consequent pneumopericardium. 

Physical Signs. — The disease is occasionally attended by pre- 
cordial bulging, with absence of the visible cardiac impulse. A 
pericardial friction sound is occasionally audible and in other 
instances succussion fremitus is demonstrable. Percussion of the 
normal area of cardiac dullness in pneumopericardium yields 
hyperresonance or tympany, while below the level of the fluid in 
the pericardium the percussion note is dull or flat. 

The heart sounds are feeble, being obscured by the pericardial 
succussion sound, which is a churning sound that has been com- 
pared to the sound produced by a water wheel in motion. Occa- 
sionallj^ a pericardial friction sound is audible. 

Diagnosis. — The pericardial succussion sound is pathognomonic 
of the disease, and its demonstration renders the diagnosis 
positive. Pneumopericardium is apt to be confused with left- 
sided pneumothorax or gaseous distention of the stomach. In 
left pneumothorax the area of cardiac dullness is not obliterated, 
and the cardiac impulse is usually visible, though frequently 
displaced toward the opposite side of the thorax. On the other 
hand, the tympanitic note' of a distended stomach disappears when 
a stomach tube is passed and the gas is liberated from this viscus. 



CHAPTER XVIII 
DISEASES OF THE ENDOCARDIUM AND VALVES 

ACUTE ENDOCARDITIS 

Clinical Pathology. — Acute endocarditis occurs in two forms ; 
namely, as simple acute endocarditis, and as malignant or infective 
endocarditis. 

Acute simple endocarditis is almost invariably secondary to dis- 
ease elsewhere in the bodily economy. It is associated with the 
greatest frequency with acute rheumatic fever; while next in fre- 
quency comes acute tonsillitis, which is followed by scarlatina, and 
chorea. Any of the acute infectious diseases is liable to be com- 
plicated by acute endocarditis. Similarly, certain chronic wasting 
diseases, as carcinoma, diabetes, and chronic nephritis, are occa- 
sionally associated with acute endocarditis. 

Recurrent endocarditis is a form of acute endocarditis in which 
valves which are the site of chronic lesions suddenly ''light up" 
with acute symptoms and signs of endocarditis. Acute endocarditis 
is noted more frequently in males than in females, and the disease 
is most prevalent during the third and fourth decades. 

The lesions of acute simple endocarditis occasionally affect the 
endocardium which lines the walls of the chambers of the heart 
(mural endocarditis) ; but this number of cases is so small as to be 
negligible. In the vast majority of cases the changes are in the 
valves themselves (valvular endocarditis). 

The earliest change from the normal in the valve segments is 
noted at a point a short distance from the free edge, the point 
where the segments come into apposition when the valve closes. 
The primary change is a decrease in the size of the endothelial cells 
with a tendency to assume a cuboidal form, leaving crevices between 
the individual cells, a state which predisposes to infection of the 
stroma of the segments. In the further evolution of the disease 
fibrin is deposited upon the partially denuded areas in consecutive 
strata, finally forming in many instances excrescences upon the 
valve cusps, the verrucose type of simple endocarditis. In the 
event that fragments of these verrucoses are swept away by the 
circulating blood, they may serve as emboli and lead to thrombosis 
in the small capillaries of the lungs, brain, or an abdominal organ. 

418 



DISEASES OF THE ENDOCARDIUM AND VALVES 



419 



In the further evolution of the disease the verrucose excrescences 
upon the cardiac valves are prone to organization Avith the produc- 
tion of scar tissue, which by subsequent contraction causes perma- 
nent deformity of the valve in stenosis or incompetence. 

Malignant or infective endocarditis, although occurring occasion- 
ally as a primary infective inflammation of the endocardium, is in 
the vast majority of cases secondary to infective disease in more 
remote portions of the body, developing during the course of puer- 
peral sepsis, osteomyelitis, acute rheumatic fever, or is secondary 




Fig 164. — Kndocarditis, verrucose form. (From Delafield and Prudden.) 



to erysipelas or acute gonorrhea. Not infrequently malignant 
endocarditis attacks cardiac valves which are the site of chronic 
endocardial inflammation. 

In this form of acute endocarditis purulent collections are formed 
in the connective tissue stroma of the valve segments, the vessels 
dilate and new vessels from the adjacent myocardium invade the 
valve stroma. There is a tendency toward repair by sclerosis ; but 
the diseased surface of the segment does not heal with a smooth 
endothelial surface, but with irregular, villous processes and ex- 



420 PHYSICAL DIAGNOSIS 

crescences, leaving the valves incompetent or stenotic. Perforation 
of a segment is not infrequent. Infectious emboli are apt to be 
carried away from the diseased valves by the circulating blood and 
to initiate metastatic abscesses in distant organs of the body. 

Physical Signs. — Inspection. — In acute simple endocarditis in- 
spection may yield no physical signs ; but in cases of recurrent endo- 
carditis, in which an acute exacerbation of a chronic endocarditis 
is in progress, there are apt to be in evidence signs of moderate 
cardiac hypertrophy; namely, displacement of the apex beat, an 
increase in the force and in the extent of the cardiac impulse, and 
frequently systolic pulsation of the carotid arteries. In malignant 
endocarditis, if cardiac dilatation is imminent, the cardiac impulse 
is feeble and rather diffuse, and is displaced from its normal loca- 
tion in the fifth intercostal space. 

Palpation. — The findings upon palpation in acute endocarditis 
are variable, varying with the duration of the disease and with 
the form of the disease which is under examination. In recurrent 
endocarditis the impulse is forcible and heaving, as a rule, as the 
result of cardiac hypertrophy, and is displaced from its normal 
site. Not infrequently in this type of the disease a systolic thrill 
may be defined at one or more of the valve areas. In simple 
endocarditis in general the cardiac impulse becomes progressively 
more feeble as the disease progresses; and in malignant endo- 
carditis when cardiac dilatation is imminent the impulse is 
commonly slapping and weak upon palpation of the precordia. 

Percussion. — During the early stage of the disease the area of 
cardiac dullness is normal ; but in recurrent endocarditis it is 
commonly extended in one or more directions, most frequently 
toward the left and downward, as a result of cardiac hypertrophy. 

Auscultation. — In both simple and malignant endocarditis aus- 
cultation frequently elicits a systolic murmur at the mitral or 
aortic valve area; but this finding does not constitute a path- 
ognomonic sign of acute endocarditis. However, when the murmur 
develops upon a slightly prolonged or roughened first sound of the 
heart, indicating coincident stenosis, endocarditis is suggested. In 
the recurrent form of the disease the murmurs of preexisting 
valvular disease are audible ; and if it is possible to detect changes 
in the quality of these murmurs in daily examinations, it is prob- 
able that an acute endocarditis has developed upon a previous 
valvular lesion. The pulmonic second sound is commonly accentu- 
ated. 

Diagnosis. — In the diagnosis of acute simple endocarditis the 



DISEASES OF THE ENDOCARDIUM AND VALVES 421 

history of the case is very important. A history of rheumatic 
fever, acute tonsillitis, or other acute infectious disease, coupled 
with the meager physical findings, may suggest a diagnosis. Of 
the physical signs the most important is a systolic murmur at the 
mitral area, particularly if this develops upon a prolonged and 
roughened first sound of the heart. Of course, the murmur must 
be distinguished from a functional murmur ; but whereas the mur- 
mur of acute endocarditis is most frequently audible in the mitral 
area, functional murmurs are most commonly elicited at the pul- 
monic area. Moreover, a functional murmur very rarely involves 
the aortic valve, over which a murmur is apt to be audible in 
acute endocarditis. 

In the diagnosis of malignant endocarditis regurgitant diastolic 
murmurs are suggestive in a measure, as functional murmurs are 
systolic in time. When, moreover, there is a history of previous 
septic infection and evidence of metastatic infection in other por- 
tions of the body, the diagnosis is still more probable. Moreover, 
malignant endocarditis is attended by fever of a septic type, with 
precordial distress, and leucocytosis. However, it should be 
remembered that malignant endocarditis presents a varied symp- 
tomatology, sometimes occurring in a cardiac form in which the 
murmurs of chronic valvular lesions i3redominate the picture; in 
a pyemic form with symptoms primarily of metastatic involve- 
ment; in a typhoid form, which closely simulates the course of 
typhoid fever; and finally in a type in which cerebral symptoms 
as delirium or coma, predominate the picture. 

Differential 'Diagnosis. — From typhoid fever it is differentiated 
by the more abrupt onset of endocarditis, the absence of the step 
ladder ascent of the fever during the first week, and the presence of 
precordial distress and dyspnea with chills and leucocytosis, which is 
in marked contrast to the leucopenia of typhoid fever. 

CHRONIC ENDOCARDITIS 

Clinical Pathology. — Chronic endocarditis is usually secondary 
to acute endocarditis, particularly to that form occurring in 
association with acute rheumatic fever and acute tonsillitis. 
Other cases of chronic endocarditis arise in persons who have 
not previously had acute endocarditis, but arise as the result of 
the constant circulation in the blood of the toxins of lead, alcohol, 
syphilis, gout, and diabetes. Laborious occupation may initiate 
the sclerotic process in the aortic segments, as also may arterio- 



422 



PHYSICAL DIAGNOSIS 



sclerosis and chronic nephritis by raising *blood pressure in the 
general circulation. 

The changes in the valves consist of a progressive sclerosis, 
frequently with the ultimate deposition of calcium salts. The 
valves are thickened, inelastic, and their free borders occasion- 
ally coalesce, producing a condition of permanent stenosis or in- 
competence. Moreover, in many cases the chordas tendinese are 




Fig. 165. — Chronic endocarditis. (Delafield and Prudden.) 

shortened and thickened so that they no longer permit of close 
coaptation of the free borders of the valve segments. 

The myocardium of the chamber of the heart upon which the 
burden is thrown by the stenotic or incompetent valve hyper- 
trophies, to be followed ultimately by myocardial degeneration 
and cardiac dilatation. 

Physical Signs. — The physical signs of chronic endocarditis are 
essentially those of chronic valvular disease, varying in their 
clinical manifestations with the valve or valves involved. 



DISEASES OF THE ENDOCARDIUM AND VALVES 423 

CHRONIC VALVULAR DISEASE 

Chronic valvular lesions of the heart are of two types: stenotic, 
which are produced by narrowing of the orifice, offering an obstruc- 
tion to the onward flow of the blood stream ; and regurgitant, which 
are produced by the inability of the valve cusps to prevent the 
regurgitation of the blood stream, owing to deformity of the valve 
cusps, shortening of the chordae tendineae, or temporary stretching 
of the valvular ring so that the normal segments are incapable of 
closing the abnormally large orifice. Not infrequently a lesion of 
a valve which produces stenosis also results in regurgitation, in- 
competence, or insufficiency. 

The valves upon the left side of the heart are much more fre- 
quently the sites of chronic lesions than are those of the right 
side. Acquired lesions of the valves of the right side of the heart 
are very rare, the vast majority of lesions upon this side depend- 
ing upon congenital malformation of the valves. However, ac- 
quired lesions do occur in this portion of the valvular mechanism 
of the heart, usually as the ultimate result of left-sided valvular 
lesions. Mitral lesions are more frequent than are any other 
valvular lesions; aortic lesions coming second in frequency, while 
lesions of the valves of the right side of the heart are very rare. 

Effects of Valvular Lesions. — The effects of valvular lesions of 
the heart are exerted upon the blood stream, upon the myo- 
cardium, and upon the lungs, abdominal organs and extremities. 

The immediate effect of a valvular lesion is to decrease the 
amount of circulating blood in front of the lesion and to increase 
the amount of blood behind the lesion ; hence, to lower the blood 
pressure in the arterial system and to raise the blood pressure in 
the venous system. In stenotic lesions only a portion of the 
contents of the chamber of the heart which discharges through 
the stenotic orifice is expelled at each systole of this chamber, 
and it at the same time receives a certain physiologic amount of 
blood from the source which discharges into it ; while in regurgi- 
tant lesions at each systole the incompetent valve permits a 
certain portion of the contents of the chamber in advance of the 
lesion to fall back into the chamber behind it, which coincidentally 
is receiving its physiologic quota from its source of supply. In 
either event an increased load is thrown upon the chamber of 
the heart, with a coincident decrease in arterial pressure and a 
corresponding increase in venous pressure. 

If there were no means of balancing the disproportion between the 
pressures hi the two circulations, arterial and venous, death would 



424 PHYSICAL DIAGNOSIS 

supervene shortly upon the establishment of h, valvular lesion of the 
heart. But to offset the difference in pressure in the two systems the 
chamber of the heart upon which the increased burden is thrown, 
compensates for the incompetence of the valve by hypertrophy of the 
myocardium, and the imbalance is temporarily corrected. So long as 
compensation or compensatory hj^pertrophy of the myocardium is 
maintained, the valvular lesion is unattended by subjective symp- 
toms ; but when the myocardium is overtaxed and fails adequately 
to respond, compensation is said to be broken, and physical signs 
and S3"mptoms rapidly supervene. 

The effects of valvular lesions are well illustrated by the sequence 
of events following aortic stenosis. When this valve is partially 
obstructed, the left ventricle is unable to adequately expel its con- 
tents during systole ; an increased burden is thrown upon the 
chamber which is receiving its normal quota of blood from the left 
auricle, and the myocardium yields and the ventricle dilates. In 
response to the increased demand for work, however, the ventricle 
hypertrophies and restores once more the imbalance between the 
arterial and venous circulations. So long as this hypertrophy is 
maintained, or so long as compensation is not broken, no change is 
noted in the general circulation; but the time ultimately arrives 
when the ventricular musculature is no longer able to sustain the 
extra burden and dilatation of the left ventricle gradually super- 
venes. 

The dilatation of the left ventricle, affecting the mitral ring, per- 
mits stretching of the ring, and the cusps of the valves are unable 
to adequately close the orifice, with the result that a certain amount 
of blood regurgitates into the left auricle during ventricular systole, 
the period of the cardiac cycle during which the auricle is receiving 
blood from the lungs. Under the influence of this double supply and 
increased burden the left auricle dilates, to ultimately hypertrophy 
in compensation for the valvular insufficiency. In course of time 
this temporary hypertrophy yields to dilatation, when, by virtue 
of the regurgitation of blood from the left ventricle, which the 
dilated auricle is unable to expel during systole, the blood pressure 
in the pulmonary circulation is raised, as evinced by accentua- 
tion of the pulmonary second sound. The continuous engorgement 
of the pulmonary circulation predisposes to catarrhal inflammation 
of the lung, and in more extreme grades, to edema of the lung, or 
hydrothorax. 

The increased strain which is thrown upon the right ventricle by 
the accumulation of blood in the lesser circulation results in dilata- 



DISEASES OF THE ENDOCARDIUM AND VALVES 425 

tion of the right ventricle, with stretching of the tricuspid ring and 
the development of a systolic "safety-valve" murmur at this orifice. 
In course of time the right ventricle by hypertrophy offsets for a 
time the effects of the pulmonary congestion, finally to undergo 
permanent dilatation, with the recurrence of tricuspid regurgita- 
tion. The right auricle undergoes the same cycle of dilatation, 
temporary hypertroplw and permanent dilatation, with a perma- 
nent tricuspid regurgitation, systolic pulsation of the liver, and 
general venous stasis with edema of the lower extremities, ascites, 
or general anasarca. 



Fig. 166. — Fenestration of semilunar valves. (From Delafield and Prudden.) 

AORTIC REGURGITATION (AORTIC INSUFFICIENCY; 
AORTIC INCOMPETENCE; CORRIGAN'S DISEASE) 

Clinical Pathology. — Accurate and complete closure of the 
aortic valve is dependent upon accurate coaptation of the free 
borders of the cusps of the semilunar valve, which are forced 
together by the arterial pressure in the root of the aorta just 
subsequent to the completion of ventricular systole. When, as a 
sequel of recent endocarditis, vegetations are formed upon the 
valvular cusps, accurate coaptation of the valve segments does 
not occur during ventricular diastole and a portion of the blood 
which is expelled from the ventricle during its systole is allowed 
to regurgitate into the ventricular chamber during diastole. 
Similarly, shrinking and sclerosis of the segments occurring as 
a result of chronic endocarditis prevents accurate coaptation of the 
cusps with the induction of regurgitation at the aortic orifice. In 



426 PHYSICAL DIAGNOSIS 

this class of cases there are frequently adhesions between the indi- 
vidual cusps. In yet other instances there is fenestration of one 
or more cusps, arising as a congenital defect, or as the result of 
ulcerative endocarditis. But there is another group of cases in 
which, without any disease or deformity of the valvular cusps, 
the fibrous ring at the aortic orifice is enlarged with the result 
that the normal valvular cusps are no longer capable of closing 
the abnormally large aortic orifice, resulting in the induction of 
relative aortic regurgitation. This change is encountered in con- 
nection with syphilitic aortitis and aneurysm of the ascending 
portion of the aorta. In yet another group of cases aortic re- 
gurgitation develops as the consequence of a slow sclerosis of the 



^^/fjarich 






closed 



Left 



Fig. 167. — Normal ventricular systole. Mitral valve is closed; aortic valve is open. 

valvular segments and aortic ring, occurring as part and parcel of 
generalized arterial sclerosis in middle-aged male subjects who have 
for years followed strenuous occupations. Mineral intoxication, 
particularly plumbism, is the initiating cause in certain cases, 
whereas other cases develop in subjects of a gouty diathesis. Aortic 
regurgitation is prone to develop during middle life, although 
isolated cases are picked up in younger subjects ; and the vast 
majority of the cases occur in the male sex. 

The mechanical influences of the lesion in aortic regurgitation are 
classified as primary, as they are exerted upon the myocardium, and 
as secondary, as they are expended upon more remote organs and 
tissues of the body. As a result of the progressive and consecutive 
manifestation of these influences, three distinct stages or periods 



DISEASES OF THE ENDOCARDIUM AND VALVES 



427 



of the disease may be diagnosed and employed by the examiner as 
a basis for his prognosis and treatment of the disease. 

Dnring the first stage of the disease the brunt of the lesion falls 
upon the left side of the heart and the arterial system, and the myo- 
cardial changes are limited to the left auricle and left ventricle. 
During the second stage of the disease, with the gradual failure of 
the left heart, the pressure rises in the pulmonary circulation and 
the lesion is compensated by hypertrophy of the right ventricle. 
Finally, the third and terminal stage of the disease is ushered in 
with failure of right ventricular hypertrophy and engorgement of 
the 2'eneral venous circulation. 



Aottic^Vo'lucS 




Fig. 168. — Normal ventricular diastole. Mitral valve is open. Aortic valve is closed. 

During the f^rst stage of the disease the primary effect of the 
aortic lesion is exerted upon the left ventricle during its diastole, 
at which period it becomes the target for two streams of blood en- 
tering its chamber simultaneously, the one propelled into the 
ventricle by left auricular sj^stole, the other regurgitating into the 
ventricle from the aorta by reason of the incompetent semilunar 
valves. Under the stress of this added burden the left ventricle 
undergoes a transient dilatation which is compensated by hyper- 
trophy of the myocardium of this chamber of the heart. So long 
as this compensatory hypertrophy is maintained, the ventricle is 
capable of expelling its contents during ventricular systole and 
no added burden is thrown upon the pulmonary circulation. 



428 



PHYSICAL DIAGNOSIS 



Upon the general arterial circulation, however, the regurgitant 
lesion exercises a decided influence. At each ventricular systole an 
excessive quantity of blood is expelled into the aorta, and this 
quota of blood is expelled with undue force by the hypertrophied 
ventricle. In this manner the arterial system is abruptly sur- 
charged with blood during ventricular systole, resulting in an 
abrupt rise in arterial pressure, which is almost immediately fol- 
lowed by as abrupt a fall during ventricular diastole. The effect 
of the sudden expulsion of the ventricular contents is to distend 
the arteries which undergo a transient dilatation, with subsequent 
collapse, producing a pulse wave which not infrequently extends 
into the capillaries as the capillary pulse of Quincke, and which is 




tral 



169. — Aortic regurgitation. Mitral and aortic valves are open during diastole. 



occasionally demonstrable in the superficial veins as the centripetal 
venous pulse. The strain which is thus thrown upon the aorta and 
general arterial system tends to provoke generalized arterial sclero- 
sis in which the coronary arteries share, with consequent myocardial 
degeneration. 

As the disease progresses, the left ventricle hypertrophies to an 
excessive degree in its effort to supply the tissues of the body with 
their normal quota of arterial blood, resulting in the cor hovinum of 
this disease. During the first stage of the disease the subject of the 
malady is troubled with recurrent transient failures of compensa- 
tion which are compensated by subsequent restoration of compensa- 
tion by the left ventricle under repose; but the time eventually 
arrives when through myocardial weakness the ventricle undergoes 



DISEASES OF THE ENDOCARDIUM AND VALVES 429 

dilatation beyond the power of compensation and the mitral valve 
yields with the establishment of relative mitral regnrgitation. In 
other instances the mitral valve is attacked by endocarditic changes 
occurring as a result of the continued hypertension in the left 
ventricle, but the usual mechanism of the establishment of mitral 
insufficiency is through dilatation of the ventricle. 

With the establishment of mitral regurgitation the second stage 
of the disease is ushered in with embarrassment of the pulmonary 
circulation and compensation by hypertrophy of the right ventricle, 
as evinced by accentuation of the second sound of the heart at the 
pulmonic area. In the vast majority of cases the establishment of 
relative mitral insufficiency during the course of aortic regurgita- 
tion is to be considered a distinctly benign complication of the 
disease, and one which is compensated by right ventricular hyper- 
trophy over a prolonged period of time. In most cases in which 
relative mitral insufficiency develops, it occurs as a signal that the 
compensatory hypertrophy of the left ventricle is unable to keep 
pace with the tendency toward dilatation from nutritional changes 
in the myocardium, and may be likened to the safety-valve leak of 
tricuspid insufficiency which for a time relieves the strain thrown 
upon a laboring right heart later in the course of the disease. 

During the second stage of the disease bronchial inflammation is 
frequently an annoying feature of the case, the intensity of the 
symptoms and signs varying with the reserve power of the right 
ventricle. 

Compensation by right ventricular hypertrophy is maintained 
for a variable period in aortic regurgitation ; but with the continued 
hypertension existing in the pulmonary circulation the reserve 
power of the right heart is overtaxed, and with the supervention of 
right ventricular failure the third stage of the disease ensues. The 
right ventricle under these circumstances fails through one of two 
mechanisms. The tricuspid valve, in the presence of the progressive 
increase in intraventricular pressure may yield and permit a 
portion of the contents of the ventricle to regurgitate into the 
right auricle during ventricular systole in the absence of any 
definite yielding of the right ventricular wall, with the establish- 
ment of the so-called "safety-valve leak" of the tricuspid orifice. 
If, on the contrary, the tricuspid valve retains its integrity in the 
presence of the progressive rise in the intraventricular pressure, 
the point is attained when the right ventricle is no longer capable 
of surmounting the excessive pressure in the pulmonary artery, 
and the ventricle is only partially emptied during ventricular 



430 PHYSICAL DIAGNOSIS 

systole. To the residual blood in the right ventricle is added the 
contents of the right auricle at the succeeding auricular systole, 
and the walls of the surcharged right ventricle yield, with dilata- 
tion of the ventricle and permanent enlargement of the auriculo- 
ventricular orifice. Thus is induced the terminal primary effect 
of the regurgitant aortic lesion, with the establishment of incompe- 
tence of the tricuspid valve with dilatation of the right ventricle. 

During this late stage of the disease the secondary effects of the 
aortic lesion develop in rapid succession. The venous return from 
the trunk and extremities, pouring into the right auricle from the 
ven£e cav^, encounters a distinct resistence in the regurgitant 
lesion at the tricuspid valve. The ultimate result is a marked 
diminution of the volume of blood which reaches the arterial cir- 
culation and a dangerous increase of the volume of blood contained 
in the venous system. As a diminished volume of blood is expelled 
at each systole of the right ventricle, the left heart is only partially 
filled, the left ventricle contracts upon a markedly diminished 
quota of blood and there is a progressive fall in arterial tension. 
On the other hand, as a result of the progressive stasis in the venous 
system, passive congestion of the lungs and abdominal viscera 
develops, together with effusion into the pleura and peritoneum, 
and the extravasation of fluid into the cellular tissues of the body. 

Aortic regurgitation is not infrequently associated with stenosis 
of the valve, particularly in cases of endocarditic origin. In these 
cases the lesion which prevents accurate coaptation of the valvular 
cusps during ventricular diastole likewise produces narrowing of 
the orifice during ventricular systole. 

In the first and second stages of the disease the subject of aortic 
regurgitation does not present many symptoms unless he be sub- 
jected to sudden strain. There is moderate dyspnea upon exertion, 
and occasionally considerable nervous irritability. With the failure 
of compensation by the right ventricle, bronchial symptoms come to 
the fore and the subject complains of digestive disturbances, fre- 
quently of considerable duration. Dizziness frequently occurs from 
cerebral anemia, and, indeed, sudden death may result from em- 
bolism of the brain. Coronary disease may induce attacks of an- 
gina, and as the disease progresses dyspnea gives place to orthopnea, 
with excessive cough and the raising of blood-tinged expectoration. 

Physical Signs. — Inspection. — In the first stage of aortic regur- 
gitation the cardiac impulse is forceful ; its area is more extensive 
than in the case of the impulse of the normal heart; and the im- 
pulse is displaced toward the left and downward as a result of left 



DISEASES OF THE ENDOCARDIUM AND VALVES 431 

ventricular hypertrophy. The impulse is observed to be heaving 
and slightly prolonged, and frequently the area of impulse is sur- 
rounded by a circumscribed area of systolic retraction of the thorax. 
As left ventricular hypertrophy progresses, the apex beat is ob- 
served to occupy a site farther and farther from the median line of 
the thorax. A very characteristic sign of the disease is systolic 
pulsation visible over the carotids in the lower cervical region, and 
frequently there are visible pulsations of the subclavian and the 
brachial arteries. The capillary pulse of Quincke is demonstrable 
in many cases of the disease and in a smaller number, a centripetal 
venous pulse is to be detected. 

In the second stage of aortic regurgitation there is a striking 
diminution in the intensity of the signs emanating from the hyper- 
trophied left ventricle as hypertrophy gives place to dilatation. 
The cardiac impulse becomes less forceful and more diffuse and 
undulatory, while at the same time being carried farther from the 
median line and downward. The systolic pulsations of the arteries 
decrease in force and eventually disappear. The respiratory move- 
ments of the thorax now become more frequent and the facies is 
anxious. Systolic pulsation of the epigastrium is commonly en- 
countered from right ventricular hypertrophy. 

During the third stage of the disease the cardiac impulse is very 
diffuse, feeble, and undulatory, occupying a broad area along the 
left sternal border between the third and sixth interspaces. The 
positive venous pulse appears in the jugulars with the establish- 
ment of tricuspid insufficiency, and this same state is frequently 
attended by a systolic pulsation of the liver. The subject suffers 
with dyspnea and harassing cough, and is no longer able to assume 
the dorsal decubitus. 

Palpation. — In the first stage of the disease with the maintenance 
of left ventricular hypertrophy the cardiac impulse is heaving and 
forceful, with great lifting power, and is frequently immediately 
followed by a moderate retraction of the thoracic wall in the vicin- 
ity of the impulse. As left ventricular dilatation becomes imminent 
the apex beat becomes appreciably enfeebled and rather slapping 
than thrusting as in the first instance. A diastolic thrill is occa- 
sionally to be detected at the aortic area, though a thrill is not 
present with aortic regurgitation with the same constancy as in 
the case of stenosis of this orifice. 

In the second stage of the disease, with the establishment of 
mitral regurgitation and hypertrophy of the right ventricle, the 
cardiac impulse is perceptible farther toward the median line and 



432 PHYSICAL DIAGNOSIS 

downward toward the epigastrium. A distinct systolic pulsation of 
the upper epigastrium is almost constantly present with hyper- 
trophy of the right ventricle. 

With the progressive failure of the right ventricle which ushers 
in the third stage of aortic regurgitation, the cardiac impulse be- 
comes feeble, diffuse, and undulatory, at the same time extending 
beyond the right sternal margin and well downward into the epi- 
gastrium. The positive venous pulse is demonstrable in the jugular 
vein by compression of the vessel above the clavicle, and systolic 
pulsation of the liver can usually be detected by bimanual palpa- 
tion of the hepatic region. 

The pulse of aortic regurgitation is of the water-hammer or 
Corrigan type, with an abrupt distention of the artery which is 
followed immediately by collapse of the vessel. This character of 
pulse is readily detected by grasping the forearm just above the 
wrist and elevating the subject's arm above the level of the heart, 
whereupon the force of gravity facilitates the emptying of the 
artery during ventricular diastole. With the inception of mitral 
regurgitation in the second stage of the disease the volume of the 
radial pulse is diminished and its rhythm is disturbed; and with 
the failure of the right ventricle the pulse is feeble, rapid and 
running, and is totally arrhythmic. 

Percussion. — Percussion of the anterior surface of the thorax in 
aortic regurgitation gives an outline of cardiac dullness which 
varies directly with the changes which occur in the size and shape 
of the chambers of the heart. During the first stage of the disease 
the transverse dullness of the heart is extended to the left and 
downward as a result of left ventricular hypertrophy. At this 
period of the disease the apical area is quite discrete and pointed, 
to become rounded and obtuse with the establishment of right ven- 
tricular hypertrophy in the second stage of the disease. At this 
time the transverse dullness of the heart is increased toward the 
right of the sternum, where it encroaches upon the vesicular reso- 
nance of Ebstein's cardiohepatic angle, and is extended downward 
into the upper epigastrium. With the supervention of dilatation 
of the right ventricle the cardiac outline extends further to the 
right of the sternum and downward into the upper portion of the 
epigastrium. In cases which are associated with aneurysm of the 
ascending aorta, percussion of the area of vascular dullness at the 
base of the heart yields an extension of dullness to the right of the 
sternum in this region. 

Percussion of the pulmonary bases during the first and second 



DISEASES OF THE ENDOCARDIUM AND VALVES 433 

periods of the disease yields little, if any, alteration in the character 
of the percussion sounds elicited. In the third stage of the disease, 
however, with the establishment of pulmonary edema, there is 
dullness over the bases posteriorly; and, in the presence of hydro- 
thorax, there is frank flatness over the distribution of the effusion. 
Similarly, during the terminal stage of the disease the areas of 
hepatic and splenic dullness are found to be extended, as a result 
of chronic passive congestion of these organs. 

Auscultation. — In aortic regurgitation there is generated a mur- 
mur with its point of maximum intensity at the aortic valve area 
near the junction of the second right costal cartilage with the 
sternum, or over the middle of the gladiolus, or near the apex of the 
heart. The point of maximum intensity of this murmur is thus 
variable ; but in the majority of instances it will be localized in the 
aortic area in the second right interspace. The line of transmission 
of the murmur passes in the majority of cases downward along the 
right sternal margin toward the ensiform cartilage, though occa- 
sionally it crosses the median portion of the sternum and is con- 
ducted to the apex of the heart. The murmur usually replaces the 
second sound of the heart at the aortic area, but in certain cases 
both murmur and second sound are audible. 

The quality of the murmur is variable during the different stages 
of the disease, and its quality and intensity are also dependent upon 
the character of the underlying lesion and upon the degree of re- 
gurgitation. During the first stage of the disease with the main- 
tenance of left ventricular hypertrophy with its excessive output of 
blood at each ventricular systole the murmur is commonly loud 
and blowing, but seldom as harsh as is the murmur of aortic steno- 
sis. The narrower the orifice through which the blood stream re- 
gurgitates, the harsher is the murmur. Similarly a prolongation 
of the murmur points to a narrow orifice at the incompetent valve. 
A brief ''whiff" at this area, on the contrary, in which the mur- 
mur occupies only the early portion of diastole and is quickly at- 
tenuated and disappears, points to a wide orifice with the regurgi- 
tation of a more considerable quantity of blood. 

With dilatation of the left ventricle and the establishment of 
relative mitral regurgitation during the second stage of the disease 
the murmur at the aortic area loses much of its intensity, and there 
is added a soft, blowing systolic murmur at the mitral area, which is 
transmitted downward and toward the left axilla, and is attended 
by accentuation of the pulmonic second sound. There is occasion- 



434 PHYSICAL DIAGNOSIS 

ally generated at the mitral area the murmtir of Austin Flint, the 
mechanism of which has been described in a previous section. 

With the supervention of right ventricular failure in the third 
stage of the disease, the murmurs at the aortic and mitral areas 
become feeble or are entirely inaudible; the formerly accentuated 
pulmonic second sound gives place to an enfeeblement of this 
sound; and the systolic murmur of tricuspid regurgitation be- 
comes audible in the tricuspid area. 

In every case of suspected aortic regurgitation the examiner 
should endeavor to pick up a transmitted diastolic murmur over 
the carotid arteries. During the first stage of the disease this 
murmur is usually quite distinctly audible, to become enfeebled 
or lost during the second and third stages of the disease. Simi- 
larly, auscultation of the femoral artery will occasionally elicit 
the double murmur of Duroziez in aortic regurgitation. 

As aortic regurgitation and stenosis not infrequently coexist, 
the examiner will occasionally detect a double '^ see-saw murmur" 
at the aortic area, the one systolic and harsh in quality, tiie other 
diastolic and more musical and less intense. 

Diagnosis. — The diagnosis of aortic regurgitation is as a rule 
readily made upon the physical findings which are presented. 
The presence of a diastolic murmur with its point of maximum 
intensely localized in the aortic area and transmitted downward 
and toward the left, the signs of immense hypertrophy or dilata- 
tion of the left ventricle, pulsations in the carotid arteries, the 
water-hammer pulse, and Duroziez 's double femoral murmur, are 
the cardinal signs upon which the diagnosis is based. 



AORTIC STENOSIS 

Clinical Pathology. — Simple stenosis of the aortic valve is the 
least frequently encountered of all acquired valvular lesions of 
the heart, and the cases occur more frequently as part and parcel 
of general arteriosclerosis in middle-aged subjects than as a 
sequela of acute endocarditis attacking the valvular segments. 
Thus, in the majority of instances, the valvular change consists of 
a gradual and progressive sclerosis of the cusps and sclerotic 
contraction of the aortic ring, resulting in diminution in the 
caliber of the aortic orifice. Aortic stenosis occasionally arises 
as a result of congenital malformation of the valve, in which event 
the lesion may consist of a fusion of the cusps with a mere slit 
or chink between the free borders of the leafiets. In yet other 



DISEASES OF THE ENDOCARDIUM AND VALVES 435 

cases the valve segments are the site of numerous excrescences 
which project into the lumen of the orifice during ventricular 
systole with the induction of narrowing of the physiologic ori- 
fice of the valve at this period of the cardiac cycle. 

But if organic derangement of the aortic valve is a rare lesion, 
there are, nevertheless, a number of possible factors which are 
capable of generating a systolic murmur at this valve in the 
absence of organic disease of the aortic ring or segments. In the 
presence of simple endocarditis the segments may bear minute 
excrescences which, while producing no actual stenosis of the 
orifice, are sufficient to produce fluid veins with the generation 
of a systolic murmur with its point of maximum intensity at the 



\ atxd 



J^e^t Julicic 







Fig. 170. — Aortic stenosis. Mitral valve is closed during ventricular systole. Aortic 

orifice is stenotic. 

aortic area. Similarly, dilatation of the proximal segment of the 
aorta just distal to the semilunar valve is capable of generating 
a murmur at this valve area in the absence of any diminution 
in caliber of the aortic orifice, constituting in this instance relative 
aortic stenosis. Also in the anemic and debilitated subject, with 
impoverishment of the circulating blood, functional murmurs which 
are systolic in time are occasionally generated at the aortic valve. 
Hence, when a systolic murmur is encountered at this valvular 
area, the burden is upon the examiner to exclude organic disease of 
the aortic valve. 

As in the case of aortic regurgitation, the course of the disease 
in aortic stenosis is insidious in onset and extended in its evolution 



436 PHYSICAL DIAGNOSIS 

and course, and in its clinical manifestations ^nd its effects upon the 
myocardium and bodily economy may advantageously be divided 
into three stages. During the first stage of the disease the myocard- 
ial changes are limited to the left side of the heart ; during the second 
stage the burden falls upon the pulmonary circulation and the 
right ventricle; and during the third stage the mechanical influ- 
ences of the lesion are expended upon the general venous system 
with the supervention of right ventricular failure. 

Again, as in the case of other valvular lesions of the left heart, 
the mechanical influences of the aortic lesion are classified as 
primary, as they are expended upon the myocardium ; and second- 
ary, as they are expended upon the venous system and their in- 
fluence is felt by more remote organs and tissues of the body. 

During the first stage of aortic stenosis there is a progressive 
hypertrophy of the left ventricle in response to the increased de- 
mand which is made upon this chamber of the heart in adequately 
expelling its contents through the narrowed aortic orifice into the 
aorta. As the onset of the disease is slow and insidious, this hyper- 
trophy develops slowly, keeping pace with the progress of the 
lesion or with the progressive rise in peripheral resistance in arte- 
riosclerotic cases, with a primary and transient dilatation of the 
chamber of the ventricle. During this period of the disease com- 
pensation is frequently broken by excessive physical exertion upon 
the part of the patient, only to be restored by repose and freedom 
from exertion. But with the progress of the disease, the point 
is reached when the ventricle is no longer capable of compensating 
for the lesion by hypertrophy, and ventricular dilatation super- 
venes with yielding of the left auriculoventricular ring and the 
establishment of relative mitral regurgitation. The establishment 
of the mitral insufficiency relieves the laboring ventricle by a 
reduction of intraventricular pressure, but it serves to increase the 
tension of the pulmonary circulation and to throw an added burden 
upon the right ventricle, which hypertrophies in response to the 
increased demand for work. 

The second stage of the disease, which is ushered in with the in- 
duction of relative mitral insufficiency is readily recognized by 
the accentuation of the pulmonary second sound which ensues upon 
right ventricular hypertrophy and the increasing hypertension in 
the pulmonary circulation. The course of the second stage of aortic 
stenosis pursues the same course as has been detailed in the section 
upon aortic regurgitation. 

The third stage of aortic stenosis is ushered in with failure of 



DISEASES OF THE ENDOCARDIUM AND VALVES 437 

the hypertrophiecl right ventricle, the changes occurring in a 
similar manner and with similar results as in the case of aortic 
regurgitation. 

As a rule, the lesion which produces stenosis of the aortic valve 
also renders the valve segments incapable of completely closing the 
orifice during ventricular diastole, so that aortic stenosis and re- 
gurgitation frequently coexist in the same subject. 




Fig. 171. — Chronic endocarditis with coalescence ot two aortic cusps. (From Delafield 

and Prudden.) 

Physical Signs.—Inspection.— During the first stage of the dis- 
ease, with the maintenance of adequate compensation by left ven- 
tricular hypertrophy a moderate displacement of the apex-beat 
outward and downward is frequently the only visible evidence of 
disease of the cardiovascular system. Upon more minute study the 
impulse is frequently observed to be increased in extent and to be 
slow and heaving. There are many elderly subjects of the disease, 



438 PHYSICAL DIAGNOSIS 

however, in whom the intervention of the anterior borders of em- 
physematous lungs between the heart and the chest wall entirely 
obscures the visible cardiac impulse. 

During the second stage of aortic stenosis, with failure of the 
left ventricle, the cardiac impulse is carried farther toward the 
left axilla and downward, and is occasionally represented by a 
broad impulse along the left sternal border in the third, fourth, 
and fifth interspaces. At this time also, as a result of right ven- 
tricular hypertrophy, systolic pulsation of the epigastrium is fre- 
quently in evidence. In children and in female subjects precordial 
bulging is frequently encountered. 

With failure of the right heart in the third stage of the dis- 
ease, venous engorgement becomes a prominent part of the clinical 
picture, with frequently systolic pulsation of the jugulars as a 
sequence of tricuspid leakage, and prominence of the abdomen and 
swelling of the feet and ankles from the effusion of fluid. 

Palpation. — During the first stage of aortic stenosis the findings 
upon palpation of the precordia are characteristic of the disease. 
The cardiac impulse is slow, forceful, and sustained, possessing a 
great degree of lifting power. In the presence of immense left 
ventricular hypertrophy there is frequently a concomitant negative 
recoil of the surface adjacent to the impulse. In the latter portion 
of the first stage, when left ventricular dilatation becomes imminent, 
there is a progressive diminution in the lifting power of the im- 
pulse, which becomes more brief and is suggestive of a slapping 
movement of the cardiac apex. 

Aortic stenosis is attended by a systolic thrill at the aortic area, 
a thrill the intensity of which is dependent upon the degree of 
stenosis and upon the contractile power of the left ventricle. The 
more rigid and unyielding is the aortic ring from sclerosis or cal- 
careous deposit, and the greater the hypertrophy of the left ven- 
tricle, the more intense is the systolic thrill at the aortic area. 
With the advent of imminent failure of the left heart there is a 
progressive diminution in the intensity of the thrill, which finally 
becomes imperceptible. 

When the left ventricle dilates and mitral regurgitation is es- 
tablished during the second stage of the disease the cardiac impulse 
loses its forceful lifting character, to become feeble, slapping, and 
undulatory. The valve shock over the pulmonic area becomes ac- 
centuated as a result of right ventricular hypertrophy, and palpa- 
tion of the hepatic region may reveal a pseudopulsation which is 



DISEASES OF THE ENDOCARDIUM AND VALVES 439 

due to the transmitted impact against this organ of the right 
ventricle during its forcible systole. 

During the third stage of the disease the cardiac impulse is 
feeble and undulatory, with irregularity of both force and rhythm. 
A thrill at the aortic area is not to be encountered at this late stage 
of the disease, and failure to detect a thrill during the later periods 
of the disease is not conclusive evidence of the absence of aortic 
stenosis. 

The pulse in aortic stenosis is slow and sustained for an appreci- 
able interval beneath the palpating finger. Its volume is dimin- 
ished, the diminution varying with the degree of stenosis and the 
compensation by left ventricular hypertrophy. "With the finger 
upon the radial artery the examiner is instinctively reminded of the 
slow and forcible systole of the hypertrophied left ventricle, expell- 
ing its contents through a narrowed aortic orifice. The sphygmo- 
graphic tracing of the pulse of aortic stenosis exhibits a prolonged 
and oblique anacrotic limb, capped by a prolonged plateau, and 
followed by a slow descent to the base line. During the last stage 
of the disease the pulse is rapid, diminished in force and volume, 
and totally disordered in rhythm. 

Percussion. — During the first stage of the disease, so long as 
left ventricular hypertrophy is moderate, little or no alteration 
may be encountered in the area of cardiac dullness. With the 
progress of the disease there is a progressive extension of the dull- 
ness toward the left axillary line and downward. In the interpre- 
tation of percussion findings in this disease the examiner should 
make due allowance for alveolar distention of emphysema if such 
be present. 

With left ventricular dilatation in the second period of the 
disease the cardiac outline extends farther to the left and down- 
ward, while the region of the cardiac apex becomes rounded or 
obtuse from the presence of hypertrophy of the right ventricle. 

With right ventricular failure in the terminal stage of the disease 
the cardiac outline extends well to the right of the sternum, en- 
croaching in this situation to a variable degree upon the angle of 
vesicular resonance of Ebstein at the junction of the areas of 
cardiac and hepatic dullness. 

Percussion of the bases of the lungs at this late stage of the 
disease usually yields bilateral dullness arising from pulmonary 
edema, and occasionally the frank flatness of a hydrothorax is 
elicited upon one side. Similarly, the areas of hepatic and splenic 



440 PHYSICAL DIAGNOSIS 

dullness may be found extended, as a result of enlargement of these 
organs from chronic passive congestion. 

Auscultation. — Aortic stenosis is attended by the generation of a 
systolic murmur with its point of maximum intensity at the aortic 
valve area in the second intercostal space adjacent to the right 
sternal border, whence the murmur is transmitted upward into the 
great vessels of the neck. The intensity and quality of the murmur 
are dependent upon the degree of stenosis and power of the ven- 
tricular systole. During the first stage of simple aortic stenosis 
only the one murmur is audible upon auscultation of the precordia. 
In the presence of slight endocarditic lesions upon the cusps of the 
aortic valve, in the group of cases which are included under the 
term ''aortic roughening," the murmur is of minor intensity, is 
blowing and not unmusical and consumes only the early portion of 
ventricular systole. Such a murmur is followed by a perceptible 
interval, after which the second sound is audible with great purity 
at the aortic area. A murmur of this type is only transmitted a 
short distance from its point of maximum intensity, and frequently 
is unattended by a palpable thrill. But in the presence of marked 
stenosis of the aortic orifice with rigidity of the ring and cusps the 
murmur is harsh and intense and is transmitted well into the root 
of the neck. This murmur consumes the whole of ventricular sys- 
tole, and as ventricular systole under these circumstances is pro- 
longed and sustained, the murmur possesses a commensurate 
duration, entirely replacing the first sound of the heart at the 
aortic area, and frequently it is followed by an impure second 
sound or by the murmur of aortic regurgitation. 

During the second stage of the disease the murmur at the aortic 
area becomes progressively diminished in intensity; its range of 
diffusion is more closely restricted to the aortic area ; and ausculta- 
tion of the cardiac apex will reveal the blowing systolic murmur 
of relative mitral insufficiency. At the same time the pulmonary 
second sound at the second left intercostal space is markedly ac- 
centuated as a consequence of right ventricular hypertrophy. 

With failure of the right heart during the third stage of the 
disease there is a progressive diminution of the intensity of the 
aortic systolic murmur, which frequently becomes inaudible late in 
the disease. At the same time the pulmonary second sound loses 
its accentuation with the development of the soft blowing safety- 
valve leak at the tricuspid orifice. 

Auscultation of the bases of the lungs now reveals the presence 
of numerous moist rales, or the respiratory murmur may be abol- 



DISEASES OF THE ENDOCARDIUM AND VALVES 441 

islied over an extensive area in the presence of effusion into the 
pleural cavity. 

Diagnosis. — The detection of a harsh systolic murmur with its 
point of maximum intensity at the aortic area and transmitted up- 
ward into the root of the neck, attended by a palpable thrill, and 
a slow, forceful, and heaving apex beat which is displaced to the 
left and downward assures the diagnosis of stenosis at the aortic 
orifice. In no other disease of the heart do we see a greater con- 
trast than that which is presented in this disease between the 
powerful and heaving apex beat and the small radial pulse of 
aortic stenosis. 

The murmur of relative aortic stenosis, which is caused by dilata- 
tion of the aorta distal to the valve, is systolic in time, but it is 
unattended by alterations of the radial pulse or ventricular hyper- 
jtrophy ; and it is attended by pulsations of the carotid vessels, 
accentuation of the aortic second sound, and an extension of dull- 
ness to the right of the sternum. 

Functional murmurs are only occasionally encountered at the 
aortic area. When present, they are musical, transient, and 
not transmitted beyond the limits of the precordia. They do 
not cause alterations in the cardiac outline or the pulse, and are 
usually encountered in young or anemic subjects. 

MITRAL REGURGITATION (MITRAL INSUFFICIENCY; 
MITRAL INCOMPETENCE) 

Clinical Pathology. — Complete closure or competence of the 
mitral orifice is dependent upon accurate coaptation of the seg- 
ments of the valve, active traction upon the cusps exerted by the 
papillary muscles through the medium of the chorcige tendine^, 
and a proper degree of contraction of the left ventricle, the three 
factors interacting in a characteristic manner and in a definite tem- 
poral sequence. Accurate coaptation of the free borders of the 
valvular cusps at the commencement of ventricular systole com- 
pletely closes the aurieuloventricular orifice ; the simultaneous 
contraction of the papillary muscles through the medium of the 
chordae tendinege, by exerting traction upon the valvular leaflets, 
prevents eversion of the segments into the auricle ; while the con- 
traction of the left ventricle diminishes by one-half the caliber of 
the left aurieuloventricular orifice and at the same time converts 
the circular orifice into an oval aperture, which is effectually 
closed by the cusps of the mitral valve, supported by the fibrous 



442 PHYSICAL DIAGNOSIS 

ring at their bases and controlled by the* papillary muscles and 
chordae tendineas. 

A disturbance in this delicately regulated mechanism may oper- 
ate through any one of its component parts to produce faulty 
closure of the valve segments with resulting incompetence. Acute 
endocarditis by the production of excrescences upon the valvular 
segments or through ulceration and partial destruction of a cusp ; 
chronic endocarditis through thickening, sclerosis or adhesion of 
the cusps; chronic interstitial myocarditis through fibrosis of the 
auriculoventricular ring which supports the cusps; and sclerosis 
of the papillary muscles through the exertion of undue traction 
upon the cusps ; all may result in regurgitation at the mitral valve. 



Left 

^ VI ancle 




Diseased 
Jfctr^L 



^eft 



Fig. 172. — Mitral regurgitation. Mitral and aortic valves open during ventricular systole. 

Similarly, in the presence of left ventricular dilatation and myo- 
cardial degeneration, the contraction of the ventricle may prove 
insufficient to reduce an auriculoventricular orifice which is unduly 
large, and the chordae tendine^ may not permit the accurate co- 
aptation of the normal cusps, with the consequent induction of 
relative mitral regurgitation. Stenosis or insufficiency of the aortic 
valve as well as bodily states which are attended by marked hyper- 
tension of the greater circulation, such as general arteriosclerosis, 
chronic interstitial nephritis, and cirrhosis of the liver, are very 
productive of regurgitation at the mitral valve. 

The mechanical influences of mitral regurgitation are primary, 
as they are exerted upon the myocardium, and secondary as they 
affect more remote organs and tissues of the body. The clinical 



DISEASES OF THE ENDOCARDIUM AND VALVES 443 

manifestations of these influences upon the circulatory imbalance 
which is induced by the mitral lesion vary in direct proportion to 
the degree of incompetence and with the extent to which the dis- 
turbance in function is compensated by hypertrophy of the myo- 
cardium. 

During the first stage of mitral regurgitation the brunt of the 
lesion is expended upon the left side of the heart. The imperfect 
coaptation of the mitral cusps permits a variable quantity of blood 
to regurgitate into the chamber of the left auricle during ventricu- 
lar systole. At this period of the cardiac cycle, which corresponds 
to auricular diastole, the left auricle is receiving the discharge of 
blood which is returned from the lungs by the pulmonary veins. 
Thus, the auricle becomes the target for two streams of blood, the 
one entering its chamber from the pulmonary veins, the other re- 
gurgitating from the left ventricle. The fusion of the two streams 
results in the induction of the so-called ''fluid veins," with the 
generation of an endocardial murmur ; and under the influence of 
these factors the surcharged auricle undergoes a transient dilata- 
tion, which is followed by compensatory hypertrophy of its wall, 
whereby it discharges an excess of blood into the left ventricle at 
each auricular systole. But the mitral insufficiency is still there and 
not all of this increased auricular output is propelled by the left 
ventricle into the aorta during its systole. On the contrary, at each 
ventricular systole a portion of the ventricular blood is returned to 
the auricle ; and to compensate for the extra burden which is thrown 
upon it, the left ventricle undergoes compensatory hypertrophy^ 

In this early stage of the disease the organic change is limited to 
the left side of the heart. During a period which is variable the 
hypertrophied left auricle is capable of expelling its contents dur- 
ing systole, and during this time there is no embarrassment of the 
pulmonary circulation and no extra demand is made upon the 
right ventricle. Similarly, for a time the hypertrophied left 
ventricle expells approximately the physiologic quantity of blood 
into the aorta during its sj^stole, and the normal tension of the 
general circulation is maintained. 

After a period varying with the reserve power of the left heart, 
the second stage of the disease ensues, in which the mechanical in- 
fluences of the mitral lesion are exerted upon the pulmonary circu- 
lation and the right ventricle. The hypertrophied left auricle is 
now no longer capable of completely expelling its contents during 
systole, and dilatation beyond the power of compensation ensues. 
The onward progress of the pulmonary circulation is progressively 



444 PHYSICAL DIAGNOSIS 

impeded, and a condition of hypertensioi^ is established in this 
circuit, as evinced by accentuation of the pulmonary second sound. 
The persistent hypertension induces a varying grade of sclerosis of 
the pulmonary arterial system, which adds further to the burden 
thrown upon the right ventricle. At the same time chronic ca- 
tarrhal inflammation of the bronchial mucous membranes is prone 
to develop. 

The right ventricle undergoes compensatory hypertrophy in re- 
sponse to the increased demand for work, a hypertrophy which 
during a variable period of time is capable of compensating for the 
leakage at the mitral valve, and one which progressively increases 
up to a point which is dependent upon the integrity of the tri- 
cuspid valve and the reserve power of the myocardium. As long 
as the right and left ventricles, acting in unison, are capable of 
propelling an adequate quantity of blood through the pulmonary 
and the greater circulations, there is no apparent imbalance be- 
tween the two systems. But when this equilibrium is disturbed, 
the right ventricle dilates beyond the power of compensation, and 
the third stage of the disease is ushered in with failure of the right 
heart and passive congestion of the general venous system. 

With the progressive hypertension in the pulmonary circuit, the 
right ventricle fails through one of two mechanisms. The tricus- 
pid valve, in the presence of the rising intraventricular pressure 
may yield and permit a portion of the blood to regurgitate into the 
right auricle during ventricular systole even in the absence of 
definite yielding of the ventricular wall, constituting the so-called 
''safety-valve leak" of this orifice. If, on the contrary, the tri- 
cuspid valve retains its integrity in the presence of the progressive 
rise in the intraventricular pressure, the point is reached when the 
right ventricle is no longer capable of surmounting the excessive 
pressure in the pulmonary artery. Under these circumstances the 
ventricle is only partially emptied during ventricular systole. To 
the residual blood in the right ventricle is added the contents of 
the right auricle at the succeeding auricular systole ; and the walls 
of the surcharged ventricle yield, with enlargement of the auriculo- 
ventricular orifice. In this manner is induced the terminal primary 
effect of the mitral lesion, with the establishment of incompetence 
of the tricuspid valve, constituting relative tricuspid insufficiency. 

At this stage of the disease the secondary effects of the mitral 
lesion develop in rapid succession. The venous return from the 
trunk and extremities, pouring into the right auricle from the 
vense cavge, encounters a distinct resistance in the regurgitant 



DISEASES OF THE ENDOCARDIUM AND VALVES 445 

lesion at the tricuspid valve. The ultimate result is a marked 
diminution of the volume of blood which reaches the arterial 
circulation and a dangerous increase of the volume of blood con- 
tained in the venous system. As a diminished volume of blood 
is expelled at each systole of the right ventricle, the left ven- 
tricle is only partially filled during diastole, and there is a pro- 
gressive fall in the general arterial tension. On the other hand, 
as a consequence of the progressive stasis in the venous system, 
passive congestion of the lungs and abdominal viscera develops 
together with effusion into the serous sacs and cellular tissues of 
the body. 

Mitral regurgitation is not infrequently associated with steno- 
sis of the valve, particularly in cases of endocarditic origin. In 
these cases the lesion which narrows the auriculoventricular ori- 
fice likewise prevents accurate coaptation of the cusps during 
ventricular systole. 

Eegurgitation at the mitral valve is attended by few symptoms 
in the first stage when compensation is as yet unbroken. Physi- 
cal exertion is usually followed by moderate shortness of breath 
or a fit of cough with the expectoration of a little frothy sputum, 
which occasionally is tinged with blood. In the second and 
third stages of the disease, owing to the embarrassment of the 
pulmonary circulation, symptoms of bronchial inflammation de- 
velop with various grades of dyspnea, which finally eventuates in 
frank orthopnea. Cough is now a constant accompaniment of the 
disease. Expectoration is profuse, the sputum containing numer- 
ous desquamated alveolar epithelial cells which contain blood 
pigment, the so-called "heart-failure cells." 

The subject of advanced mitral regurgitation is subject to dis- 
turbances of digestion, and with the progressive venous stasis the 
development of hemorrhoids is frequently an annoying symptom 
of the case. 

Physical Signs. — Mitral regurgitation in the course of its evolu- 
tion produces a multiplicity of physical signs, Avhich arise in the 
main as the result of the primary effects of the lesion upon the 
myocardium and partially as a manifestation of the secondary 
effects of the incompetence upon the pulmonary and general cir- 
culations. In no disease of the heart can the clinician more read- 
ily correlate cause with effect or base a more accurate prognosis 
upon the physical findings than in mitral regurgitation. With the 
progress of the disease, there is a progressive augmentation in 
the physical findings, the paucity of physical signs in the first 



446 PHYSICAL DIAGNOSIS 

stage of the disease presenting a striking contrast to the profusion 
of signs and symptoms which are in evidence during the later 
periods of the disease. 

Inspection. — During the first stage of mitral regurgitation, when 
the changes in the myocardium are limited to the left side of the 
heart, inspection is apt to prove negative, save for a displacement 
of the cardiac impulse toward the left and downward, as a result 
of left ventricular hypertrophy. The degree of apical displace- 
ment is, however, quite variable. In the adult subject it is not 
apt to be as extensive as in children, in whom the apex-beat may 
be encountered external to the left axillary line. Likewise, in 
young subjects, owing to the elasticity of the thorax, a moderate 
degree of bulging of the precordia is occasionally induced by the 
progressive enlargement of the left heart. 

During the second stage of the disease, with the development and 
maintenance of right ventricular hypertrophy, the cardiac impulse 
is displaced farther toward the left axilla and is visible over a more 
extensive area toward the median line and the epigastrium. Sys- 
tolic pulsation of the epigastrium is almost a constant accompani- 
ment of right ventricular hypertrophy. A similar pulsation not 
infrequently is visible in the second and third intercostal spaces 
adjacent to the left sternal border, occurring as a result of left 
auricular dilatation. At this period of the disease the cardiac im- 
pulse is powerful and heaving, in marked contrast to the feeble, 
slapping, and undulatory impulse following upon complete decom- 
pensation of the myocardium. 

In the third stage of the disease, with the advent of right ventric- 
ular dilatation, the discrete and forcible impulse of the heart 
progressively gives place to a feeble, undulatory pulsation, which 
is commonly visible along the left sternal border from the third to 
the sixth intercostal spaces, and frequently also in the epigastrium 
along the left costal arch. At this time also the positive venous 
pulse is demonstrable in the jugular veins as a result of tricuspid 
leakage, and occasionally there is a systolic hepatic pulsation aris- 
ing as a result of the same lesion. 

At the same time signs of general venous stasis appear, as evinced 
by edema of the feet and ankles, progressive abdominal enlargement 
from ascites, chronic cough with the raising of serous, sometimes 
blood-streaked expectoration, together with acceleration of the 
respiratory movements of the thorax and cyanosis of the mucous 
membranes, auricles, and digits. In chronic cases of extensive dura- 
tion clubbing of the fingers is frequently seen, and these subjects 



DISEASES OF THE ENDOCARDIUM AND VALVES 447 

often exhibit a tortuosity and distention of the superficial veins of 
the neck and chest. 

Palpation. — During the maintenance of left ventricular hyper- 
trophy in the first stage of the disease the cardiac impulse is jiis^ 
Crete, forceful, and heaving upon palpation of the precordia. In 
a relatively small percentage of cases of pure mitral regurgitation 
a fine systolic thrill is to be detected over the cardiac apex. A 
thrill is, however, much more commonly encountered in the cases 
of combined stenosis and regurgitation at the mitral orifice. 

In the second stage of the disease, with the development of com- 
pensatory hypertrophy of the right ventricle, the palpable impulse 
of the heart becomes more extensive, while preserving its force. 
Systolic lifting of the lower costal margin and upper epigastrium 
is frequently to be detected, as well as a systolic shock communi- 
cated to the liver by the overacting right ventricle. 

With the progressive failure of the right ventricle during the 
third stage of the disease the cardiac impulse becomes progressively 
enfeebled, diffuse, and wavy, frequently extending to the right 
of the sternum and well into the epigastrium. Positive systolic 
pulsation of the jugular veins is to be detected by compression of 
the vein just above the clavicle, a simple maneuver which abolishes 
a true systolic jugular pulsation and thus serves to distinguish it 
from a false pulsation communicated to the vein from the subjacent 
carotid artery. 

The pulse in mitral regurgitation is to a large degree indicative 
of the state of the left ventricle throughout the course of the dis- 
ease. So long as compensation is maintained, the radial pulse is 
of constant volume and tension and its rhythm is usually little dis- 
turbed. Moderate acceleration is frequently present, however, and 
there exists a small group of cases in which arrhythmia is a strik- 
ing feature throughout the course of the disease. With the super- 
vention of left ventricular dilatation the volume of the pulse is 
markedly reduced, acceleration is more marked, and irregularity 
of both force and rhythm is always demonstrable. In the third 
stage of the disease not every ventricular systole is sufficiently 
powerful to produce a radial pulse. 

Percussion. — The transverse dullness of the heart is increased 
toward the left and downward as a consequence of the bilateral 
ventricular hypertrophy which attends the disease. So long as 
hypertrophy is limited to the left side of the heart, the outline of 
cardiac dullness at the apex remains pointed ; but in the second 
stage of the disease, with the establishment of right ventricular 



448 PHYSICAL DIAGNOSIS 

hypertrophy, there is a progressive rouncfing of the cardiac out- 
line at the apical area, while the dullness extends farther to the 
right of the sternum. In the late period of the disease, with the 
establishment of tricuspid insufficiency, the examiner may fre- 
quently detect an extension of cardiac dullness upward in the third 
and fourth intercostal spaces upon either side of the sternum, as 
a result of auricular dilatation. 

The pulmonary bases should be carefully and methodically per- 
cussed during every examination of a subject of mitral regurgita- 
tion with the object of detecting a complicating pulmonary edema 
or hydrothorax. This examination commonly proves negative dur- 
ing the period of maintained compensation during the first and 
second stages of mitral regurgitation. But with the rupture of 
compensation in the third stage of mitral insufficiency percus- 
sion of the pulmonary bases yields impairment of vesicular reso- 
nance due to pulmonary edema, or flatness over the inferior portion 
of the thorax as a result of hydrothorax. 

Similarly, a routine examination in this disease should not be 
considered complete without the careful delimitation of the areas of 
hepatic and splenic dullness. With the maintenance of compensa- 
tion in the first and second stages of the disease these areas of dull- 
ness retain their normal dimensions ; but with failure of compen- 
sation and the general venous stasis which attends this state the 
areas of hepatic and splenic dullness are increased in extent as a 
result of passive congestion of the venous radicles of these organs. 

Atiscultation. — Mitral regurgitation in the first period of its 
evolution is attended by a systolic murmur with its point of max- 
imum intensity at the mitral area, over the apex of the heart. From 
this site the murmur is propagated in all directions ; but it is trans- 
mitted with selective intensity toward the left axillary region ; and 
occasionally it is audible upon the posterior aspect of the thorax 
near the angle of the scapula. The murmur is blowing rather than 
harsh and unmusical, and it partially or completely obscures the 
first sound of the heart at the apex. The quality and intensity of 
the murmur vary with the condition of the myocardium and with 
the posture assumed by the patient. A murmur which is faintly 
audible in the erect posture frequently becomes accentuated 
when the subject assumes the recumbent posture. During the first 
stage of mitral regurgitation there is no perceptible accentuation 
of the second sound of the heart at the pulmonic area, a negative 
finding which, by excluding the existence of right ventricular 



DISEASES OF THE ENDOCARDIUM AND VALVES 449 

hypertrophy, indicates that the myocardial changes are as yet 
limited to the left heart. 

During the second stage of the disease, on the contrary, accentua- 
tion of the pulmonic second sound is clearly perceptible, affording 
a perfectly reliable sign of compensation of the mitral lesion by 
right ventricular hypertrophy. But before basing deductions as to 
the extent of the mitral lesion upon the degree of accentuation of 
the pulmonic sound, the examiner must needs exclude the presence 
of obstructive disease of the lungs, and must take into consideration 
the age of the patient, bearing in mind the physiologic accentua- 
tion of this sound in the young subject. 

During the first and second stages of the disease auscultation of 
the pulmonary bases yields no signs of congestion of the lungs or 
pulmonary edema ; and so long as the mitral leakage is adequately 
compensated by right ventricular hypertrophy, the intensity of the 
mitral murmur remains uniform in intensity, in striking contrast 
to the enfeeblement of the murmur which is encountered in the last 
stage of the disease. 

With the failure of compensation by the right ventricle there is 
a progressive enfeeblement of the accentuated pulmonary second 
sound, with the coincident generation of the systolic murmur of a 
' ' safety-valve leak" at the tricuspid orifice. As the systolic murmur 
of tricuspid insufficiency with its point of maximum intensity over 
the lower sternal region gains in intensity, there is a progressive 
enfeeblement of the mitral systolic murmur, which is audible over 
an ever-diminishing area, to finally become masked entirely by the 
increasing intensity of the tricuspid murmur. 

In this late stage of the disease auscultation of the pulmonary 
bases yields numerous moist rales, which are universally distrib- 
uted over both lungs. 

Diagnosis. — The presence of a systolic murmur at the cardiac 
apex, which is blowing and not unmusical in quality, and which 
is transmitted toward the left axilla and is associated with ac- 
centuation of the pulmonic second sound constitutes a clear pic- 
ture of mitral regurgitation. In the early stage of the disease, 
however, when the myocardial changes are limited to the left side 
of the heart, accentuation of the pulmonic sound is not perceptible. 
Under such circumstances the examiner should seek for displace- 
ment of the cardiac impulse toward the left and downward, oc- 
curring from left ventricular hypertrophy. 

In relative mitral regurgitation the examiner w^ill usually elicit 



450 PHYSICAL DIAGNOSIS 

■ » 

signs of general hypertension and a murmur at the aortic orifice 
which is altogether more intense than is the mitral murmur. 

The intensity of a mitral murmur to a certain degree is indica- 
tive of the nature of the causative lesion. Thus the mitral 
systolic murmur of acute endocarditis is soft and blowing in 
quality and is attended by little ventricular hypertrophy ; whereas 
mitral regurgitation occurring as a result of chronic endo- 
carditis with shrinking and sclerosis of the valve segments yields 
a loud blowing murmur, which is attended by considerable en- 
largement of the transverse dullness of the heart. 

Differential Diag'nosis. — Functional murmurs are prone to de- 
velop at the mitral valve, although they are more frequently en- 
countered at the pulmonic valve. Nevertheless, the examiner 
should bear in mind that the mitral valve comes second in point 
of frequency for these murmurs. But, as previously noted, these 
murmurs do not produce vejatricular hypertrophy neither are they 
propagated beyond the limits of the precordia, and usually they 
are encountered in the anemic and debilitated subject. 

The systolic murmur of aortic stenosis is frequently audible at 
the mitral area as well as at the aortic area ; but in this instance the 
examiner will experience little difficulty in determining that the 
point of maximum intensity of the murmur is localized in the aortic 
area, and that its line of propagation is upward into the root of 
the neck and not at all toward the left axillary region. Moreover, 
the quality of the two murmurs is quite dissimilar. The murmur 
of aortic stenosis is loud and harsh as compared with the softer 
''whiif" of the mitral regurgitant murmur, and aortic stenosis is 
almost constantly attended by a palpable thrill in the aortic valve 
area. 

Pericardial friction is frequently audible over the region of the 
cardiac apex, producing in this locality a sound with a quality not 
unlike that of the mitral regurgitant murmur. But while peri- 
cardial friction is frequently almost synchronous with the first 
sound of the heart, the sound is more diffuse in its distribution, 
and it is never transmitted from the limits of the precordia. 
Neither does the sound completely replace the first sound of the 
heart ; and moreover, it is frequently transient and evanescent and 
is influenced by pressure with the stethoscope and by changes in 
posture upon the part of the patient. 

A cardiorespiratory murmur generated near the cardiac apex 
may readily be mistaken for a mitral systolic murmur during a 
casual examination ; but this murmur does not replace the first sound 



DISEASES OF THE ENDOCARDIUM AND VALVES 451 

of the heart ; and it is markedly influenced by the respiratory ex- 
cursion of the lung, being intensified during full inspiration, and 
frequently abolished during forced expiration. 

MITRAL STENOSIS 

Clinical Pathology. — Stenosis of the mitral valve is a disease of 
adolescence and early manhood as a rule, developing usually as 
a sequence of acute endocarditis of rheumatic origin. Aside from 
the rheumatic cases may be grouped endocarditic cases arising 
as a sequence of scarlatina, chorea, chlorosis, and the acute in- 
fectious fevers. But there is another group of cases of mitral 
stenosis in which a slow sclerosis of the valvular cusps occurs in 
elderly subjects of general arteriosclerosis and chronic interstitial 
nephritis. 

The mechanical influences of the lesion in mitral stenosis are 
manifested in much the same manner as are those which accom- 
pany a regurgitant lesion at this valve, with certain variations 
which are due to the manner of inception of the primary altera- 
tions in the myocardium. As these influences operate slowly 
upon the myocardium and remote organs of the body, the disease 
may be divided into three stages, as in the case of mitral regurgi- 
tation, three stages in which one results inevitably in another 
when once an organic stenosis is established at the mitral orifice. 

During the first stage the brunt of the lesion falls upon the 
left auricle and left ventricle, and during this stage of the dis- 
ease the myocardial changes are confined to the left side of the 
heart. At the completion of ventricular systole the ventricular 
walls relax and during the early portion of ventricular diastole 
a portion of the blood which has accumulated in the left auricle 
during ventricular systole is aspirated into the chamber of the 
left ventricle. During the midportion of ventricular dias- 
tole the pressure of the blood column contained in the left 
auricle and the pulmonary veins forces a further quantity of the 
contents of the left auricle into the chamber of the left ventricle. 
Finally, during late ventricular diastole the systole of the left 
auricle propels the remainder of the blood which occupies the 
cavity of the auricle into the ventricle completing the first act 
of the cardiac cycle. In the presence of a narrowing of the 
mitral orifice an additional burden is thrown upon the left auri- 
cle, Avhich hypertrophies in response to the increased demand for 
work. So long as the hypertrophied auricle is capable of com- 



452 PHYSICAL DIAGNOSIS 

pletely emptying its contents promptly without retardation of 
the pulmonary circulation, the circulatory balance is adequately 
maintained; but as the reserve power of the auricle is limited, 
hypertrophy eventually gives way to dilatation, an increased 
burden is thrown upon the pulmonary circulation and the right 
heart and the second stage of the disease is ushered in with 
hypertrophy of the right ventricle. During this stage of the 
disease moderate left ventricular hypertrophy occurs as the re- 
sult of the aspirating action of this chamber in drawing its proper 
quota of blood through the narrowed orifice, and because it m ust 
contract powerfully in order to expel the diminished output of the 
auricle into the aorta. 




closed] 



Xef, 









Fig. 173. — Mitral stenosis. Ventricle during late diastole or presystole. 

The third stage of the disease develops when the right ven- 
tricle yields to the progressive increase in tension of the pul- 
monary circuit, the mechanism differing in no wise from that of 
mitral regurgitation. 

The valvular changes in mitral stenosis present wide variations. 
In early endocarditic cases there are merely small vegetations 
upon the auricular aspects of the cusps, which produce practically 
no stenosis, but which are sufficient to induce ''fluid veins" with 
the generation of a presystolic murmur. In more advanced cases 
the cusps are sclerosed and shrunken, frequently with adhesion 
of the free borders and shortening of the papillary muscles, with 



DISEASES OF THE ENDOCARDIUM AND VALVES 453 

the reduction of the valvular orifice into a mere slit or chink, the 
''button-hole orifice" of Corrigan. In yet other instances the 
cusps are normal, but the mitral ring is reduced in caliber either 
as a congenital defect or as a result of secondary sclerosis. 

During the first and second stages of mitral stenosis the sub- 
ject of the disease experiences little discomfort and presents 
few symptoms. Foremost among these is moderate dyspnea 
which is brought out upon severe exertion. Occasionally the first 
intimation of the existence of the disease consists in the onset 
of a local paralysis from embolism of the brain. In recurrent 
endocarditic cases the subject is likely to present recurrent 
febrile attacks which develop without assignable cause. During 
the later stage of the disease dyspnea becomes extreme, amounting 
frequently to orthopnea, with free expectoration of frothy sputum 
which is frequently tinged with blood. 

Physical Signs. — Inspection. — In the first stage of mitral steno- 
sis inspection frequently proves negative, as the principal find- 
ings upon inspection in this disease depend upon embarrassment 
of the pulmonary circulation as a result of the mitral obstruction, 
and as this obstruction is adequately compensated during the 
early period of the disease by left auricular hypertrophy. The 
cardiac impulse usually occupies its normal position in the fifth 
left interspace ; and when it is displaced by left ventricular hyper- 
trophy at this time the displacement occurs toward the left and 
not downward. The area of the impulse is very frequently re- 
duced in extent. In the case of young subjects and in women 
there is frequently a visible presystolic pulsation in the second 
and third intercostal spaces adjacent to the left sternal border, 
which is produced by left auricular hypertrophy. 

During the second stage of the disease, with the establishment 
of right ventricular hypertrophy, systolic pulsation of the epi- 
gastrium is frequently to be noted, as well as a wide systolic 
pulsation in the third and fourth intercostal spaces along the left 
sternal border, developing as a result of the impact against the 
thoracic wall of the conus arteriosus of the right ventricle. In 
children and in thin chested subjects a variable degree of bulging 
of the precordia and lower sternal region is frequently en- 
countered. 

"With failure of the right ventricle in the third stage of the 
disease the cardiac impulse becomes broad and undulatory along 
the left sternal border, together with distention of the cervical 
veins and frequently a positive jugular pulsation which is due to 



454 PHYSICAL DIAGNOSIS 

the establishment of tricuspid regurgitation. The respiratory 
movements of the thorax are labored, and the lips and mucous 
membranes exhibit cyanosis together with general pallor of the 
integument of the trunk and extremities. The abdomen protrudes 
from the accumulation of fluid in the peritoneal cavity, and the 
feet and ankles swell from edema of the cellular tissues. 

Palpation. — Palpation of the mitral area in mitral stenosis reveals 
the presence of a presystolic thrill, which is pathognomic of the 
disease. The apex beat is of normal or slightly increased force. 
The thrill at the mitral area is attended by accentuation of the 
valve shock at the pulmonic area, which attains its maximum in- 
tensity during hypertrophy of the right ventricle during the 
second stage of the disease. During the third stage of the dis- 
ease the mitral thrill becomes progressively enfeebled while the 
cardiac impulse becomes more extensive, undulatory and slapping. 

The pulse of mitral stenosis is of small volume, but of high 
tension during the maintenance of compensation, and is disor- 
dered in both force and rhythm with the failure of the right 
heart. In certain cases arrhythmia is a striking feature through- 
out the course of the disease. 

Percussion. — During the first stage of mitral stenosis percus- 
sion reveals no alteration in the cardiac outline, save in selected 
cases an extension of dullness in the third and fourth left inter- 
spaces arising from left auricular hypertrophy. During the sec- 
ond stage of the disease the area of cardiac dullness is extended 
toward the right, encroaching for a variable distance upon the 
vesicular resonance of Ebstein's cardiohepatic angle. During 
the third stage of the disease percussion of the pulmonary bases 
frequently reveals dullness from pulmonary edema ; and the areas 
of hepatic and splenic dullness are extended as a result of chronic 
passive congestion of these organs. 

Auscultation. — During the first stage of mitral stenosis auscul- 
tation at the apex of the heart in the vast majority of cases re- 
veals the presence of a presystolic murmur, which is not trans- 
mitted beyond the precordia. In cases of minor stenosis, hoAvever, 
in which a few vegetations exist upon the auricular aspect of the 
valve segments, there may be no appreciable murmur, but merely 
a roughening and accentuation of the first sound of the heart. 
In these cases active exertion upon the part of the subject will 
frequently bring a presystolic murmur to the fore, which again 
becomes inappreciable when the patient has reposed for some 
hours in the recumbent posture. 



DISEASES OF THE ENDOCARDIUM AND VALVES 455 

The quality of the murmur of mitral stenosis defies adequate 
description; it must be heard to be appreciated. The murmur 
is harsh, ingravescent or crescendo in quality, increasing steadily 
in intensity from commencement to termination, and is followed 
by a sharp first sound of the heart. During the first stage of the 
disease, during the maintenance of left auricular hypertrophy, 
the murmur is generated immediately prior to ventricular sys- 
tole, and the first sound of the heart at the apex, in the absence 
of coincident mitral regurgitation, remains clearly perceptible. 
The murmur of mitral stenosis is not transmitted beyond the 
limits of the precordia. 

During the second stage of the disease, with the establishment 
of right ventricular hypertrophy, the mitral murmur develops 
slightly earlier in diastole and is well sustained throughout auric- 
ular systole, with an intensity which equals or exceeds that of 
the murmur during the first period of the disease^ Auscultation 
of the pulmonic area during this stage of the disease reveals a 
striking accentuation of the pulmonic second sound, and not in- 
frequently there is a reduplication of the second sound of the 
heart at the base. 

With the failure of compensation by the right ventricle during 
the third stage of the disease the mitral murmur becomes pro- 
gressively more feeble, to finally become inaudible or to become 
obscured by a systolic murmur at the tricuspid area arising as a 
result of tricuspid regurgitation. There is at the same time a 
progressive enfeeblement of the formerly accentuated second 
sound of the heart at the pulmonary area. Auscultation of the 
pulmonary bases at this stage of the disease yields numerous 
moist rales, which are universally distributed over both lungs. 

Diagnosis. — The diagnosis of mitral stenosis is based upon the 
characteristic physical findings; namely, a presystolic murmur at 
the mitral area, ingravescent or crescendo in quality, followed by 
a distinct and snapping first sound of the heart, and not trans- 
mitted beyond the precordia, with increase in the transverse dull- 
ness of the heart, particularly toward the right, and with accen- 
tuation of the pulmonary second sound at the base of the heart. 
There are, however, a number of possible confusing findings, and 
a differential diagnosis is not always unattended by considerable 
difficulty. 

Differential Diagnosis. — Foremost among the confusing factors 
in the diagnosis of mitral stenosis stands the Flint murmur of 
aortie^regurgitation. In the exclusion of this possible source of 



456 PHYSICAL DIAGNOSIS 

error the examiner should search for the a^ortic organic murmur 
occurring at the base of the heart in this disease, the capillary 
pulse of Quincke and the femoral murmur of Duroziez. The 
quality of the two murmurs is quite dissimilar, as the Flint 
murmur does not possess the ingravescent and crescendo quality 
of the murmur of true organic mitral stenosis. While both mur- 
murs occur at the mitral area and are not transmitted thence, the 
Flint murmur never possesses the same degree of intensity as is 
attained by the murmur of mitral stenosis. 

Mitral regiirgiiaiion is attended by a soft, blowing murmur at 
the mitral area, which is systolic in time, and which is transmitted 
toward the left axilla. The progress of development of the two 
murmurs is, moreover, diametrically opposed, the murmur of 
mitral stenosis progressively increasing in intensity to terminate 
in an abrupt first sound of the heart, whereas the murmur of mi- 
tral regurgitation, becomes progressively less intense from its 
commencement with ventricular systole until its termination. 
Quite frequently the two murmurs are combined, the systolic 
murmur of mitral regurgitation ensuing shortly upon the pre- 
systolic murmur of mitral stenosis, in the presence of combined 
stenosis and regurgitation at the mitral orifice. 

Tricuspid regurgitation produces a systolic murmur with its 
point of maximum intensity in the tricuspid area over the lower 
portion of the sternum, whence the murmur is propagated toward 
the right. This murmur frequently is audible in combination with 
the murmur of mitral stenosis late in the course of the disease ; but 
it is attended by such striking disorders of the venous circulation 
that a differentiation of the two murmurs is not attended by great 
difficulty. 

Tricuspid stenosis produces a presystolic murmur with its point 
of maximum intensity not far removed from that of the murmur 
of mitral stenosis. The quality of the two murmurs is not at all 
dissimilar, but stenosis of the tricuspid orifice is a rare lesion and 
usually forms a part of the syndrome of congenital cardiac disease. 

The murmur of aortic regurgitation occasionally has its point 
of maximum intensity at the mitral area; but in this instance the 
time of the murmur as well as the quality serves as a basis of differ- 
entiation. The murmur of aortic regurgitation has its inception at 
the commencement of ventricular diastole, progressively becoming 
less intense during the diastolic period to become lost before the 
beginning of the first sound of the heart. In those cases of mitral 
stenosis, however, in which the mitral presystolic murmur occupies 



DISEASES OF THE ENDOCARDIUM AND VALVES 457 

a considerable portion of the diastolic period, an error in diagnosis 
is very prone to be made. 

PULMONARY REGURGITATION (PULMONARY INSUFFI- 
CIENCY; PULMONARY INCOMPETENCE) 

Clinical Pathology. — Pulmonary regurgitation occurring as the 
result of organic disease of the pulmonary valve is the rarest of 
all acquired lesions of the heart. Isolated cases are encountered, 
however, in which as the result of ulcerative endocarditis at- 
tacking the right side of the heart, deformity of the valvular 
cusps has occurred with resulting inability of the deformed cusps 
to adequately close the pulmonary orifice. These cases are most 
frequently encountered among young adult subjects, and pul- 
monary insufficiency is usually combined with pulmonary stenosis. 
Incompetence of the pulmonary valve is one of the rare congenital 
defects of the heart. 

Relative pulmonary regurgitation, on the contrary, in which re- 
gurgitation occurs at this orifice in the absence of structural de- 
rangement of the valve, is of frequent occurrence. Relative pul- 
monary insufficiency may be of intracardiac or extracardiac 
origin. In the presence of uncompensated lesions of the left side 
of the heart, with the progressive rise in tension in the pulmonary 
circulation, the right ventricle is prone to yield with resulting 
enlargement of the ring supporting the cusps of the semilunar 
valve and the induction of relative pulmonary insufficiency. Sim- 
ilarly, in the presence of obstructive disease of the lungs of pro- 
longed duration, such as chronic ulcerative phthisis, cirrhosis 
of the lung, and hypertrophic emphysema, the persistent hyper- 
tension in the pulmonary circulation is capable of inducing rela- 
tive insufficiency of the pulmonary valve. 

The immediate effect of regurgitation at the pulmonary valve 
is to induce transient dilatation of the right ventricle, which is 
compensated by hypertrophy of its muscular walls. So long 
as compensation is maintained the circulatory imbalance is cor- 
rected; but the ventricle eventually reaches the limit of its re- 
serve power, whereupon dilatation beyond the power of compen- 
sation follows, with the establishment of tricuspid regurgitation, 
and general engorgement of the venous system. As a result of 
stasis in the pulmonary circulation edema of the lungs ensues and 
the subject exhibits the signs of chronic bronchial catarrh. 

Physical Signs. — Inspection. — In its early stages simple pul- 



458 PHYSICAL DIAGNOSIS 

monary regurgitation yields no evidence o:& its existence upon in- 
siDCction. As the disease progresses the cardiac impulse is dis- 
placed toward the left axillary line but is not displaced down- 
ward. While right ventricular hypertrophy is maintained, there 
is visible pulsation of the epigastrium, and in thin chested indi- 
viduals there is visible bulging of the lower portion of the pre- 
cordia. As the disease progresses the subject becomes dyspneic 
with chronic cough and serous expectoration, while the trunk 
and extremities are pallid as a result of deficient arterial circula- 
tion. With the establishment of tricuspid insufficiency the posi- 
tive jugular pulse becomes demonstrable in the jugular veins. 

Palpation. — During the early period of the disease with the 
maintenance of right ventricular hypertrophy the apex beat is 
diffuse and extends downward toward the epigastrium and well 
inward toward the left sternal border. A forceful, lifting systolic 
pulsation is usually to be elicited in the upper epigastrium as a 
result of the powerful contractions of the right ventricle. Sim- 
ilarly, the right costal arch is occasionally raised by the impact 
of the overacting right ventricle against the liver. Late in the 
disease a true expansile pulsation of the liver can occasionally be 
elicited upon bimanual palpation of the liver, occurring as a 
manifestation of tricuspid regurgitation. Occasionally it is pos- 
sible to elicit a fine diastolic thrill at the pulmonary area; but 
the thrill is not constantly present, neither is it detected with the 
same constancy as is the case of the systolic thrill accompanying 
stenosis of this valve. 

The pulse in pulmonary regurgitation is apt to be of low tension 
and diminished volume and arrhythmic, but presents nothing which 
is characteristic of the disease. 

Percussion. — The transverse dullness of the heart is increased to- 
ward the right in direct proportion to the degree of hypertrophy 
of the right ventricle. As dilatation ensues upon compensatory 
hypertrophy the right margin extends well to the right of the 
sternum. Late in the disease the pulmonary resonance is im- 
paired over the bases of the lungs, and the areas of dullness of the 
liver and spleen are more extensive than in the normal subject. 

Auscultation. — Auscultation of the pulmonary area reveals the 
presence of a blowing murmur with its point of maximum intensity 
at the junction of the second left costal cartilage with the sternum, 
whence it is transmitted downward along the left sternal border 
and toward the cardiac apex. The murmur is commonly blowing 
and musical, but in cases of associated pulmonary stenosis and 



DISEASES OF THE ENDOCARDIUM AND VALVES 459 

regurgitation the murmur is apt to have a harsher quality and to 
completely replace the second sound of the heart at the pulmonary 
area. In the presence of relative pulmonary insufficiency auscul- 
tation of other valve areas will elicit the murmurs peculiar to the 
organic lesions which are present. 

Diagnosis. — The diagnosis rests upon the detection of a dias- 
tolic murmur with its point of maximum intensity at the pul- 
monary area, whence it is transmitted downward, with signs of 
hypertrophy or dilatation of the right heart, and general venous 
stasis. In reaching a diagnosis of simple pulmonary regurgita- 
tion the examiner should bear in mind the relative infrequency 
with which this valve is attacked by organic disease. 

PULMONARY STENOSIS , 

Clinical Pathology. — Stenosis at the pulmonary valve is in 
the vast majority of cases due to a congenital defect and is 
associated with other congenital deformities of the heart such 
as tricuspid stenosis, patent ductus arteriosus, patent foramen 
ovale, or perforation of the ventricular septum. Very rarely 
the lesion is the sequence of ulcerative endocarditis attacking 
the pulmonary valve. 

But while true stenosis of the pulmonary valve is a rare le- 
sion, there are many pathologic conditions capable of inducing 
the generation of a systolic murmur at this valve. First and 
foremost among these factors stands anemic states with the 
induction of func^onal murmurs, which are more frequently 
encountered at the pulmonary valve than at the other valves 
of the heart. Similarly, dilatation of the pulmonary artery 
distal to the valve produces a condition of relative pulmonary 
stenosis, which is attended by a systolic murmur at this area in 
the absence of organic disease of the valve. Compression or con- 
striction of the pulmonary artery by new growths, enlarged glands, 
or pleural adhesions are all capable of inducing a murmur which 
may be mistaken for that of pulmonary stenosis. The nervous 
imbalance of the cardiac mechanism incident to exophthalmic 
goiter frequently is betrayed by a systolic murmur at the pul- 
monary valve ; and shifting of the mediastinal structures through 
cardiac displacement may produce torsion of the vessel with a 
resulting systolic murmur in the vicinity of the pulmonary 
orifice. 

The immediate effects of the lesion in stenosis at the pulmonary 



460 PHYSICAL DIAGNOSIS 

valve are expended upon the right ventricle, which hypertrophies 
to compensate for the obstruction; and if the obstruction is slight, 
no further myocardial change may be induced. In the presence of 
a greater degree of stenosis however, the persistent increase of in- 
traventricular pressure results in right ventricular dilatation, rel- 
ative tricuspid insufficiency and general venous engorgement. 

Physical Signs. — Inspection. — In cases of pulmonary stenosis of 
congenital origin, the signs upon inspection are largely those of 
congenital heart disease, notably extreme cyanosis, dyspnea and 
and clubbing of th'e fingers. In the presence of minor degrees of 
stenosis, dyspnea and a little cyanosis upon active exertion may 
remain the sole signs of the disease. When right ventricular hyper- 
trophy is a marked feature of the case the cardiac impulse is dis- 
placed toward the left and is visible also farther toward the right 
as a systolic pulsation of the upper portion of the epigastrium. 
With the supervention of tricuspid insufficiency the positive venous 
pulse becomes appreciable in the jugular veins. 

Palpation. — Palpation of the pulmonary valve area reveals the 
presence of a fine systolic thrill, which is frequently diffused over 
a wider area than is the case with the systolic thrill of aortic steno- 
sis. The thrust of the right ventricle is clearly palpable in the up- 
per epigastrium in the presence of hypertrophy of this chamber 
of the heart, and its impact not infrequently communicates a sys- 
tolic impulse to the adjacent liver. 

The pulse at no time during the course of the disease presents 
any changes which are characteristic of the disease. With fail- 
ure of the right heart its volume is reduced and its rhythm is dis- 
turbed, findings which are in no wise distinctive of the lesion pres- 
ent. 

Percussion. — Delimitation of the cardiac outline proves negative 
during the early stages of pulmonary stenosis, and in the presence 
of minor degrees of stenosis which are readily compensated by a 
slight degree of right ventricular hypertrophy the outline is little 
altered throughout the disease. With the supervention of frank 
ventricular hypertrophy, the outline is increased toward the right ; 
and in the presence of right ventricular and auricular dilatation 
the increase toward the right is further accentuated. 

With the establishment of tricuspid regurgitation and venous 
stasis the dullness of the liver and of the spleen is appreciably in- 
creased in extent. 

Auscultation. — Pulmonary stenosis is attended by a systolic 
murmur with its point of maximum intensity at the pulmonary 



DISEASES OF THE ENDOCARDIUM AND VALVES 461 

area, whence it is diffused in all directions, but with selective in- 
tensity upward toward the root of the neck, but it does not extend 
into the vessels of the cervical region as is the case with the systolic 
murmur of aortic stenosis. The murmur is audible over a consid- 
erable area of the precordia, but with care its point of maximum 
intensity can be localized to the second left intercostal space ad- 
jacent to the sternum. 

The quality and intensity of the murmur vary with the degree of 
stenosis and with the power of the ventricular contraction. The 
murmur is inherently harsh and unmusical, in marked contrast to 
the soft and blowing murmurs of functional origin occurring at 
this valve. In the presence of minor grades of stenosis, however, 
the intensity of the murmur is not great and its duration is not 
considerable. In the case of marked stenosis, on the contrary, the 
murmur is harsh, intense, and sustained, commencing with ventric- 
ular systole and terminating with the second sound of the heart, 
wiiich is not infrequently replaced by the diastolic murmur of a 
coexistent pulmonary regurgitation. 

With the establishment of tricuspid insufficiency, the systolic 
murmur of this lesion is perceptible at the tricuspid area, obscur- 
ing in this locality the first sound of the heart. 

Diagnosis. — The diagnosis of simple pulmonary stenosis rests 
upon the cardinal signs of the disease; namely, a systolic murmur 
with its point of maximum intensity at the pulmonary area, 
whence it is transmitted upward, but which does not extend into 
the great vessels of the neck; a palpable thrill at the same area, 
w^hich is to be detected in the vast majority of cases; and signs 
of right ventricular hypertrophy or of right heart failure. 

Differential Diagnosis. — Functional murmurs, which are en- 
countered at the pulmonarj^ valve more frequently than at the other 
valve areas of the heart, are systolic in time ; but they are soft and 
blowing; they are transient, coming and going at successive exam- 
inations ; they are not transmitted beyond the limits of the precor- 
dia; and they do not induce changes in the myocardium or the 
character of the pulse. " 

In the spurious murmurs which are generated at this area by 
torsion or dilatation of the pulmonary artery, by the constriction 
of the vessel by pleural adhesions, or by the disturbance of exoph- 
thalmic goiter, there is no evidence of circulatory disturbance or 
of myocaixiial changes. The patient is not dyspneic and is appar- 
ently in a good state of health. The murmurs, moreover, are more- 



462 PHYSICAL DIAGNOSIS 

■ * 

j diffuse than is the murmur of simple pulmonary stenosis, and they 
exhibit no selective line of transmission. 

Aneurysm of the aorta produces a systolic murmur which is audi- 
ble in the vicinity of the pulmonary area ; but the murmur and the 
thrill which accompanies it has a more diffuse distribution upon 
the anterior thoracic surface; it is commonly attended by local pul- 
sation and by dullness over its distribution, and its systolic mur- 
mur is transmitted into the vessels of the neck, which is not true of 
the murmur of pulmonary stenosis. 

Patency of the ductus arteriosus induces a murmur in the vicinity 
of the pulmonary area ; but the point of maximum intensity of this 
murmur is farther from the sternal margin than is the case with 
the pulmonary stenotic murmur ; and, moreover, the murmur of a 
patent ductus arteriosus continues beyond the second sound of the 
heart, which is not characteristic of the murmur of pulmonic steno- 
sis. 

TRICUSPID REGURGITATION (TRICUSPID INSUFFI- 
CIENCY; TRICUSPID INCOMPETENCE) 

Clinical Pathology. — Regurgitation occurs at the tricuspid ori- 
fice in tw^o distinct forms ; namely, as simpl^ or^ganic insufficiency 
of the valve, and as relative or functional insufficiency of the tri- 
cuspid valve. Organic disease of this valve of the heart is indeed 
rare, as the predilection of endocarditic changes is for the left 
side of the heart. Occasionally tricuspid regurgitation arises 
from congenital malformation of the valve, in which event it is 
usually combined with tricuspid stenosis. 

If organic insufficiency at the tricuspid valve is infrequent, 
relative regurgitation at this orifice, arising as a result of right 
ventricular dilatation under the stress of heightened tension in 
the pulmonary circulation, is a very frequent disease. Under 
these circumstances the tricuspid valve develops a ^'safety-valve 
leak" with the generation of a soft and blowing systolic mur- 
mur with its point of maximum intensity at the tricuspid area 
over the lower end of the gladiolus, the valvular disease con- 
stituting merely a link in the syndrome of chronic valvular dis- 
ease of the heart. Indeed, even in the absence of incompetence 
upon the part of the valves of the left heart, tricuspid regurgita- 
tion may be induced by persistent hypertension in the pulmonary 
circulation, which arises as a result of obstructive disease of the 
lungs during the course of chronic ulcerative phthisis, chronic 
interstitial pneumonia, or hypertrophic emphysema. 



DISEASES OF THE ENDOCARDIUM AND VALVES 463 

The primary effect of the tricuspid lesion is an immense dilata- 
tion of the right auricle, the reserve power of Avhich is so limited 
that auricular hypertrophy never adequately compensates for the 
lesion at the tricuspid valve. Venous engorgement appears early 
in the disease, with overfullness of the cervical veins, systolic 
pulsation of the liver, the positive venous pulse in the jugulars, 
anasarca and general edema of the extremities. 

Physical Signs. — Inspection. — In tricuspid regurgitation the 
physical signs vary with the state of the myocardium and with 
the syndrome of which tricuspid regurgitation is a part. In the 
presence of simple isolated tricuspid regurgitation of congenital 
or endocarditic origin the cardiac impulse is carried toward the 
right as a result of right ventricular hypertrophy, frequently 
occupying a position behind the sternum. In relative tricuspid 
insufficiency occurring as part and parcel of left-sided valvular dis- 
ease, on the contrary, the cardiac impulse is displaced to the left and 
downward, at the same time encroaching upon the upper epi- 
gastrium, in which site it is heaving and forceful if right ven- 
tricular hypertrophy is maintained. As the disease progresses, 
dilatation of the right auricle produces a visible pulsation along 
the right sternal border in the second, third, and fourth inter- 
spaces. 

Whatever may be the cause of the lesion, tricuspid insufficiency 
produces multiple signs of venous engorgement and general 
venous stasis. The subject is dyspneic and frequently cyanotic 
about the face, Avith anemic pallor of the trunk from deficient 
arterial circulation. The positive venous pulse is demonstrable in 
the jugular veins, and the abdomen is prominent from ascites, 
while the feet and ankles swell from edema. 

Palpation. — Palpation of the upper epigastrium reveals a sys- 
tolic pulsation, arising as the result of the impact of the right 
ventricle. In simple organic regurgitation of the tricuspid valve 
this pulsation does not possess the same degree of force which is 
exhibited in the secondary or relative form of the disease, in 
which right ventricular hypertrophy is more extreme. Bimanual 
palpation of the liver reveals the presence of a true, expansile 
pulsation of this organ which is synchronous with ventricular 
systole. A pseudopulsation of the liver is sometimes caused by 
the impact of the hypertrophied right ventricle against the liver, 
and should not be mistaken for the true expansile pulsation of the 
organ, which is a very good sign of tricuspid regurgitation. 

The pulse of tricuspid regurgitation presents no distinctive char- 



464 PHYSICAL DIAGNOSIS 

acteristics. As^^mmetry of the radial pulses is apt to arise as the 
result of compression of the right subclavian artery by the enlarged 
right auricle. 

Percussion. — In simple tricuspid regurgitation, the cardiac out- 
line extends well to the right of the sternum, with little or no 
enlargement of the left ventricle. In relative tricuspid regurgita- 
tion, on the contrary the transverse dullness of the heart is ex- 
tended both toward the right and toward the left and downward 
toward the upper epigastrium as a result of combined ventricular 
hypertrophy or dilatation. 

Percussion of the base of the thorax reveals impairment of the 
vesicular resonance as a result of pulmonary edema or frank dull- 
ness late in the disease from hydrothorax. The areas of hepatic 
and splenic dullness are extended in the late stages of the disease. 

Auscultation. — Tricuspid regurgitation is attended by a blowing 
systolic murmur with its point of maximum intensity at the tri- 
cuspid area over the lower portion of the gladiolus, whence it is 
transmitted toward the right and slightly upward. The point of 
maximum intensity of this murmur is not as discrete and circum- 
scribed as is the case with endocardial murmurs occurring at the 
other valves of the heart. Frequently the blowing murmur is 
audible over the greater portion of the precordia ; but careful 
examination will usually serve to localize its maximum intensity 
over the lower sternal region and to reveal a selective transmission 
of the murmur toward the right and upward. The first sound of 
the heart is obscured by the murmur, but is seldom entirely re- 
placed by it. The second sound varies with the concomitant state 
of the myocardium. In simple isolated tricuspid regurgitation the 
second sound is unaltered in intensity or slightly enfeebled, whereas 
in relative tricuspid insufficiency the second sound is accentuated 
during the maintenance of right ventricular hypertrophy, to be- 
come enfeebled with the supervention of right ventricular dilata- 
tion. 

Diagnosis. — The cardinal signs of tricuspid regurgitation are 
a systolic murmur with its point of maximum intensity at the 
tricuspid area, whence it is transmitted toward the right and 
slightly upward, signs of right ventricular hypertrophy, the 
positive venous pulse in the jugulars, the systolic hepatic pulse, 
and signs of general venous engorgement. In cases of relative 
tricuspid regurgitation the murmurs of the causative left-sided 
valvular lesions are to be detected. 



DISEASES OF THE ENDOCARDIUM AND VALVES 465 

TRICUSPID STENOSIS 

Clinical Pathology. — Stenosis at the tricuspid orifice ranks 
among the rarest of the valvular lesions of the heart. Tlie major- 
ity of the cases have occurred in female subjects, and the lesion is 
rarely diagnosed during life. 

Most cases of tricuspid stenosis are of congenital origin, the 
segments by fusion of their free borders leaving a merely button- 
hole or chink at the tricuspid orifice. There are cases, however, 
which are of endocarditic origin, and which are associated with 
similar stenotic lesions at the mitral orifice. 

The primary effect of the stenotic lesion is to add to the burden 
of the right auricle, which hypertrophies in response to the in- 
creased demand for work. In cases of moderate stenosis of the 
valve this compensatory hypertrophy is adequate and is main- 
tained and there is no embarrassment of the venous circulation. 
In more pronounced cases, however, right auricular dilatation 
eventually supervenes, with signs of general venous stasis, and 
effusion into the serous sacs and the cellular tissues of the body. 

Physical Signs. — Inspection. — Many cases of tricuspid stenosis 
with adequate compensation yield no physical signs for years or 
those which are exhibited are obscure and conflicting. Signs which 
point to stenosis of the tricuspid orifice comprise persistent moder- 
ate cyanosis, with distention and tortuosity "of the cervical veins, 
and occasionally a pronounced ne gative venous pulse j n_the jugular 
veins. 

Pal/pation. — Tricuspid stenosis is occasionally attended by a 
presystolic thrill which is palpable at the tricuspid area over the 
lower end of the sternum, but the thrill is not a constant finding 
in this disease. The cardiac impulse is usually encountered in its 
normal site, and its force and extent are not deranged in many 
cases. Pronounced stenosis of the valve, however, causes diminu- 
tion in the force and extent of the apex-beat, and its rhythm is apt 
to be deranged. 

The pulse is in no wise characteristic of the disease. In the 
presence of pronounced stenosis its volume is reduced and it is apt 
to be accelerated and disordered in rhythm. 

Percussion. — The cardiac outline is unaltered in many cases, 
while in the presence of right auricular dilatation the transverse 
dullness of the heart is extended to the right of the sternum in the 
third and fourth interspaces. 

Auscultation. — The lesion of tricuspid stenosis generates a pre- 
systolic murmur with its point of maximum intensity at the 



466 PHYSICAL DIAGNOSIS 

tricuspid area over the lower end of the gladiolus, whence it is not 
transmitted beyond the limits of the lower precordia. In the pres- 
ence of marked stenosis of the valve the second sounds of the heart 
are diminished in intensity at the aortic and pulmonary areas at 
the base of the heart. 

Diagnosis. — The detection of a presystolic murmur with its 
point of maximum intensity in the tricuspid area and frequently 
a presystolic thrill in the same region, with signs of venous en- 
gorgement point to tricuspid stenosis. As tricuspid and mitral 
stenosis are frequently concomitant lesions, the mitral murmur 
frequently obscures the tricuspid murmur and leads to an error 
in diagnosis. 



CHAPTER XIX 

DISEASES OF THE MYOCARDIUM 

ACUTE MYOCARDITIS (ACUTE MYOCARDIAL 
DEGENERATION) 

Clinical Pathology. — Acute myocarditis occurs clinically in two 
forms; namely, as acute parenchymatous myocarditis; and as acute 
interstitial myocarditis. 

Acute parenchymatous myocarditis occurs as a complication of 
acute infectious febrile diseases, notably pneumonia, typhus and 
typhoid fevers, scarlatina, and diphtheria. An acute myocarditis 
arising during these diseases usually has its inception during the 
active febrile stage of the disease, at which time it may be the 
cause of sudden death ; but in other instances its incidence is de- 
ferred, the disease developing and occasionally causing death dur- 
ing late convalescence. Acute parenchymatous myocarditis also 
occurs as a complication of endocarditis and pericarditis, by sec- 
ondary infection of the myocardium from the causative organism 
of these diseases. 

"While the name myocarditis implies an inflammation, the signs 
of acute inflammation are not in evidence, the characteristic 
changes in the myocardium being those of a slow degeneration or 
metamorphosis, ranging in gravity from cloudy swelling in the 
favorable cases to fatty degeneration in the grave cases. 

Grossly the heart presents a varied appearance, being pale or 
grayish-red in the presence of cloudy swelling; yellowish in fatty 
degeneration, and gray in the presence of extensive hyaline change. 
It is probable that the earliest retrogressive change in acute par- 
enchymatous myocarditis, in those cases which yield the best 
prognosis, is cloudy swelling; and that the ultimate change is 
fatty degeneration, in which the prognosis is extremely grave. 

Acute interstitial myocarditis also develops during the course of 
acute fevers, Leyden first describing the disease in connection with 
scarlatina. Rhomberg has noted the changes characteristic of the 
disease in diphtheria, typhoid fever, acute rheumatic fever, and 
variola. The disease occurs in two grades of severity ; namely, the 
transient nonsuppurative interstitial myocarditis; and the more 
grave suppurative iiiterstitial myocarditis. In the former the inter- 

4G7 



468 PHYSICAL DIAGNOSIS 

■ * 

muscular spaces of the myocardium are infiltrated with leucocytes, 
the coronary capillaries are dilated, and the muscle bundles present 
areas of vacuolation, nuclear multiplication, and pigmentation ; but 
the morbid process frequently eventuates in resolution without the 
formation of fibrous connective tissue between the muscle bundles. 

The suppurative form of the disease, of more grave prognostic 
import, is usually the sequence of infectious embolism of the coro- 
nary arteries. When one of the terminal vessels of this arterial 
system becomes occluded by a simple, noninfectious embolus, 
anemic or hemorrhagic infarction of the myocardium is apt to 
ensue; but if the occluding embolus contains infectious material, 
if its source happens to be a vegetation from the cusp of a cardiac 
valve which is the site of infective endocarditis, or from an area 
of infective osteomyelitis, a more serious lesion of the myocardium 
ensues. At the sites of obstruction circumscribed areas of leuco- 
cytic infiltration and bacterial colonization develop, leading to 
minute purulent infiltrations between the muscle bundles, weak- 
ening the heart wall and predisposing to aneurysm and rupture. 
The rupture may occur externally into the pericardial sac with 
the production of purulent pericarditis ; or the pus may discharge 
into a cavity of the heart, the organisms being distributed to 
various organs of the body by the blood stream with the production 
of metastatic abscesses. 

Instead of terminating by resolution as in the case of acute 
nonsuppurative interstitial myocarditis, the areas of purulent in- 
filtration are prone to result in the formation of fibrous patches, 
weakening the cardiac musculature and predisposing to aneu- 
rysm of the cardiac wall. 

Physical Signs. — Physical signs in this disease are often mea- 
ger, and when present, are not clear and distinctive. The cardiac 
impulse as a rule shows a primary accentuation, with a subse- 
quent weakening in its force and area. In certain cases sudden 
death may occur either during the height of an acute infectious 
disease or even late in convalescence. A fairly reliable diagnostic 
sign is an equalization of the intensity of the first and second 
sounds of the heart, both sounds assuming a valvular quality, 
with coincident signs of pulmonary stasis. Late in the course of 
the disease, when cardiac dilatation has supervened, the area of 
cardiac dullness is extended, and a relative mitral regurgitant 
murmur is frequently audible. 

Diagnosis. — The diagnosis must be reached through the dis- 
covery of a causative factor rather than upon the physical signs, 



DISEASES OF THE MYOCARDIUM 469 

which are often few and confusing. But when during the course 
of an acute infectious disease the heart tones become enfeebled, 
equalized, and valvular, with alterations in rhythm as embryo- 
cardia or gallop-rhythm, the incidence of an acute myocarditis 
may be inferred. 

Many of the cases simulate closely acute endocarditis; but in 
the latter disease the cardiac weakness is not so rapid and ex- 
treme, neither is the cardiac rhythm disturbed to an equal degree. 

CHRONIC MYOCARDITIS (CHRONIC FIBROUS MYO- 
CARDITIS; CHRONIC INTERSTITIAL 
MYOCARDITIS) 

Clinical Pathology. — Chronic myocarditis is a slow sclerosis of 
definite areas of the myocardium, developing secondarily to 
changes in the coronary arteries. The essential lesion of the 
coronary circulation which is productive of chronic myocarditis 
is a narrowing or obliteration of the lumen, the result of obliter- 
ative endarteritis or embolic occlusion. Obliterative endarteri- 
tis of the coronary circulation is merely part and parcel of 
generalized arteriosclerosis. 

When a noninfectious embolus lodges in a terminal branch of a 
coronary artery, an infarct of the myocardium is apt to form. 
The infarct is surrounded soon by a zone of infiltrating leucocytes. 
The infarct is wedge-shaped with the apex of the wedge directed 
toward the site of the embolism. The infarct, which may assume 
either the anemic or hemorrhagic type, leads to an area of soften- 
ing of the myocardium to which the term myomalacia cordis has 
been applied by Ziegler. This area is a point of lowered resistance 
to the endocardiac pressure and is liable to lead to rupture with 
sudden death. If rupture does not occur, the area of infarction is 
gradually replaced by fibrous connective tissue. 

The portions of the myocardium usually attacked are the lower 
two-thirds of the anterior wall and the upper portion of the poste- 
rior wall of the left ventricle ; the interventricular septum ; and 
the bases of the papillary muscles. 

Associated changes occurring in the heart which is the seat of 
chronic myocarditis comprise hypertrophy, dilatation, and valvular 
disease. In cases of moderate involvement there is sufiicient sound 
myocardium to compensate for the cardiac impairment by hyper- 
trophy. In more extensive fibrosis, however, there is little intact 
myocardium ; the cardiac wall yields under the normal or increased 



470 PHYSICAL DIAGNOSIS 

endocardiac pressure ; and dilatation become^ inevitable. Valvular 
disease develops in association with moderate cases of fibrosis when 
it involves the papillary muscles, even in the presence of cardiac 
hypertrophy. In cases in which the sclerotic process is extreme 
and associated with cardiac dilatation, valvular disease is a con- 
stant accompaniment. 

Physical Signs. — The physical findings in chronic myocarditis 
are not characteristic and distinctive, as they vary with the stage 
of the disease and with the state of the myocardium and the 
cardiac valves. As in the acute form of the disease, the heart 
sounds are usually less muscular and more valvular in quality; 
they are accentuated in the presence of compensatory hyper- 
trophy; and they are enfeebled after dilatation has supervened. 
The aortic second sound is frequently accentuated, as the patients 
often have arteriosclerosis. The pulse is hard and tense, fre- 
quently with stiff, unyielding arterial wall, and is often dis- 
ordered in rhythm. The area of cardiac dullness is often found 
extended as a consequence of cardiac hypertrophy or dilatation. 
Murmurs are encountered in the purely valvular cases and in 
cases associated with cardiac dilatation. 

Diagnosis. — The diagnosis of chronic myocarditis is based par- 
tially upon the physical signs, but principally upon the discovery 
of arteriosclerosis in a subject past middle life who presents such 
physical findings. Chronic dyspnea and signs of pulmonary con- 
gestion aid in establishing the diagnosis. 

CARDIAC HYPERTROPHY 

Clinical Pathology. — An overgrowth of 'the musculature of the 
heart with maintenance of its nutrition may involve a single 
chamber of the heart, one side of the heart, or the entire organ. 
The portion which is most frequently involved is the left 
ventricle. 

Thickening of the wall of the heart with enlargement of the 
chamber is termed eccentric hypertrophy. A similar mural 
change with decrease in the size of the chamber is termed con- 
centric hypertrophy, a condition which has not been demonstrated 
to exist to the satisfaction of many clinicians. 

The cause of cardiac hypertrophy is increased work thrown 
upon the heart while its nutrition is maintained. The causes of 
this overwork may reside within the heart, or without the viscus. 
The persistent and continuous muscular exertion of the athlete 



DISEASES OF THE MYOCARDIUM 471 

and of the person who is engaged in a laborious occupation is 
frequently provocative of cardiac hypertrophy. Habitual over- 
eating and the ingestion of excessive quantities of beer have been 
followed by hypertrophy of the heart. Interference with the 
cardiac action by pericardial adhesions in chronic adhesive peri- 
carditis is constantly attended by more or less hypertrophy of 
the heart, as are diseases of innervation of the heart which lead 
to continual cardiac overaction. 

Arteriosclerosis and chronic nephritis by raising the blood 
pressure in the greater circulation lead to hypertrophy of the 
left ventricle; while obstructive disease of the lung such as 
hypertrophic emphysema, chronic interstitial pneumonia, and 




Fig 174. — Enormous hypertrophy of left ventricle due to prolonged increased peripheral 
resistance. Note that the whole anterior surface of the heart is occupied by the left 
ventricle. The right ventricle does not appear to be much affected. (From Warfield.) 

phthisis, by raising the pressure in the lesser circulation lead to 
hypertrophy of the right ventricle. Left-sided valvular lesions 
are productive of hypertrophy of the left ventricle and ultimately 
of the right ventricle. Left auricular hypertrophy is caused by 
regurgitant and stenotic lesions of the mitral valve; and right 
auricular hypertrophy follows similar lesions affecting the tri- 
cuspid valve. Pregnancy is frequently attended by moderate 
hypertrophy of the heart. 

The hypertrophied heart is increased in size in one or more 
directions, occasionally reaching such an extent as to constitute 



472 PHYSICAL DIAGNOSIS 

the cor bovinum. The shape of the hypertit)phied heart varies in 
different types of hypertrophic change. In total hypertrophy of 
the heart the organ is ronghly round or spherical. In left ven- 
tricular hypertrophy and in right ventricular hypertrophy these 
portions of the heart are respectively enlarged. 

LEFT VENTRICULAR HYPERTROPHY 

Physical Signs. — Inspection. — In left ventricular hypertrophy 
the cardiac impulse is forcible and heaving and is displaced down- 
ward and toward the left. Precordial bulging is noticeable in 
children and in female subjects with thin chest walls. There is 
frequently visible pulsation of the carotid arteries. The area of 
the cardiac impulse is extended. 

Palpation confirms the displacement of the cardiac impulse and 
its firm, heaving character. The valve shock over the aortic valve 
is exaggerated. The pulse is regular, of full volume, and of high 
tension. The cardiac impulse is not increased in frequency, but it 
is powerful and heaving. The impulse may be localized in the 
sixth or seventh interspace as far outward as the anterior axillary 
line. In the presence of hypertrophic emphysema it may be im- 
possible to palpate the apex-beat owing to the intervention of the 
anterior pulmonary borders between the heart and the chest wall. 

Percussion reveals an increase in the transverse dullness of the 
heart toward the left and downward, the left border of the dullness 
frequently extending past the anterior axillary line, and the lower 
limit occupying the seventh intercostal space. 

Auscultation of the precordia reveals accentuation and occasion- 
ally reduplication of the aortic second sound. The first sound at 
the apex is similarly accentuated. There is in certain cases a sys- 
tolic murmur at the mitral area due to incompetence of the mitral 
valve. Occasionally in left ventricular hypertrophy there is a 
peculiar, tinkling sound audible to the right of the cardiac apex. 
A cardiorespiratory murmur may be encountered in certain in- 
stances due to the strong impact of the hj^pertrophied ventricle 
against a portion of the lung which is anchored anterior to the 
heart by pleural adhesions. When the cardiac valves are normal 
the first sound of the heart, in addition to its accentuation, exhibits 
a perceptible prolongation owing to the slow and powerful con- 
traction of the hypertrophied ventricle. When the hypertrophy is 
caused by or is associated with valvular lesions, or when dilatation 
is imminent, relative murmurs may be heard. 



DISEASES OF THE MYOCARDIUM 473 

RIGHT VENTRICULAR HYPERTROPHY 

Physical Signs. — Inspection. — In hypertrophy of the right ven- 
tricle there is undue prominence of the lower sternum and epi- 
gastrium, frequently combined with systolic epigastric pulsation. 
The condition is also attended by systolic pulsation along the right 
sternal border in the sixth and seventh interspaces. Pulsation is 
not infrequently noted above these levels as well, due to right 
auricular hypertrophy. The cardiac impulse is displaced to the 
right, possibly lying behind the sternum or to the right of this bone. 

Palpation reveals the presence of pulsation at the lower end of 
the sternum and in the epigastrium ; but the thrust is not as strong 
or as distinct as it is in the case of left ventricular hypertrophy. 
The valve shock over the pulmonary valve is stronger than is that 
over the aortic area. There is occasionally a palpable impulse 
transmitted to the liver by the overacting right ventricle, which 
should not be confused with the expansile systolic pulsation of that 
organ which occurs with tricuspid regurgitation. 

Percussion. — Cardiac percussion shows that the area of cardiac 
dullness is extended toward the right, occasionally extending an 
inch to the right of the sternum. 

Auscultation. — The tricuspid first sound is accentuated and some- 
what prolonged, and a systolic ''safety-valve" leak is occasionally 
demonstrable when right ventricular failure is imminent. The 
pulmonic second sound is invariably accentuated and reduplication 
of the second sound of the heart is frequently encountered. 

The pulse is of small volume, but is regular, unless dilatation is 
imminent, in which event the rhythm of the pulse is disturbed. 

LEFT AURICULAR HYPERTROPHY 

Physical Signs. — Left auricular hypertrophy is seldom to be as- 
certained by physical means. An extension of cardiac dullness 
to the left of the sternum in the second and third interspaces is 
suggestive when found; and, if the hypertrophy is due to mitral 
stenosis, the presystolic murmur of this condition may be audible. 
Or, in the event that the auricular hypertrophy is secondary to 
mitral regurgitation, a systolic murmur may be audible over the 
cardiac apex. 

RIGHT AURICULAR HYPERTROPHY 

Physical Signs. — In hypertrophy of the right auricle physical 
signs are meager, but there is apt to be an increase in the area of 



474 PHYSICAL DIAGNOSIS 

cardiac dullness to the right of the sternum in the second, third 
and fourth interspaces. Presystolic pulsation along the right 
sternal border in this region is occasionally encountered. These 
signs, with the signs of right ventricular hypertrophy and with 
a systolic murmur at the tricuspid valve area, are very suggestive 
of right auricular hypertrophy. Systolic pulsation in the jugular 
veins, with signs of general venous engorgement point to tri- 
cuspid regurgitation with right auricular hypertrophy. 

Diagnosis. — Cardiac hypertrophy is indicated by the powerful, 
heaving character of the cardiac impulse ; the increase in the area 
of cardiac dullness in one or more directions ; the accentuation 
of the second sounds of the heart; and the hard tense pulse of full 
volume. However, certain other intracardiac and extracardiac 
conditions rather closely simulate cardiac hypertrophy and re- 
quire differentiation. 

Fibroid retraction of the left lung may cause a wide impulse, 
which may during a casual examination suggest cardiac hyper- 
trojjhy. But the physical signs of cirrhosis of the lung in this 
instance are quite sufficient to render a differential diagnosis 
comparatively simple. 

Neurotic conditions incident to exophthalmic goiter, and the 
excessive ingestion of stimulants, as tea, coffee, or tobacco, cause 
transient vigorous cardiac action, simulating cardiac hyper- 
trophy; but in these conditions the impulse is less diffuse and 
heaving; the cardiac dullness is not extended; and there are 
ameliorations and aggravations of the attacks. 

In pericardial effusion the increased area of dullness is tri- 
angular or pear-shaped with the base directed downward toward 
the diaphragm; and the heart sounds are enfeebled, and the 
pulse is of the pulsus paradoxus type. 

In cardiac dilatation the heart sounds are feeble, but distinct, 
and the pulse is feeble and irregular, while cardiac murmurs are 
to be detected at one or more of the valve areas. At the same 
time there are signs of general venous stasis incident to right 
heart failure. 

CARDIAC DILATATION 

Clinical Pathology. — Cardiac dilatation is an enlargement of 
one or more chambers of the heart, occurring as a result of yield- 
ing of the myocardium which is the seat of secondary changes. 
Clinically cardiac dilatation may be said to exist when a chamber 
of the heart is no longer able to empty itself during systole. The 



DISEASES OF THE MYOCARDIUM 475 

underlying cause of cardiac dilatation resides in an increase in 
intracardiac tension or in inherent degeneration of the cardiac 
wall; and in most instances there is a combination of these two 
factors operative in the induction of cardiac dilatation. 

Physical exertion operates in two ways to produce cardiac dila- 
tation ; namely, in the form of prolonged muscular exertion in the 
form of mountain climbing or foot racing, and in the form of 
sudden, abrupt exertion in the presence of valvular heart disease or 
chronic myocarditis. 

Valvular lesions of the heart are the most fertile sources of dila- 
tation of the several chambers of the heart, the chamber passing 
through the usual cycle of temporary dilatation, transient compen- 
satory hypertrophy, and permanent dilatation. 

Myocarditis, induced by malnutrition in anemia or chronic ob- 
literative endarteritis or by the chronic irritative action of the 
toxins of syphilis and plumbism, or by the direct effects of the 
toxemia of acute infections, predisposes to dilatation of the heart. 

Increased peripheral resistence to the onward flow of the blood 
stream through the greater or lesser circulation tends to result in 
ultimate dilatation of the chamber of the heart which bears the 
brunt of the burden : arteriosclerosis and chronic nephritis raising 
the blood pressure in the general circulation, and obstructive dis- 
ease of the lungs or left-sided valvular lesions of the heart acting 
similarly upon the pulmonary circulation. 

Ventricular dilatation is associated with relative insufficiency 
caused by yielding of the fibrous ring of the auriculoventricular 
orifice, with the result that although the valvular cusps are not 
deformed, they are yet unable to close the abnormally large ori- 
fice. Moreover, the chordae tendinese and papillary muscles do 
not share in the dilatation, and remaining of normal length, they 
do not permit the accurate coaptation of the free borders of the 
valve cusps. 

Dilatation may occur with thinning of the cardiac wall or in 
association with compensatory hypertrophy with thickening of 
the myocardium. Dilatation with thinning of the myocardium is 
an acute process, usually observed in the right ventricle when this 
chamber is subjected to a sudden hypertension in the pulmonary 
circulation. Dilatation with hypertrophy, on the contrary, is a 
slower and more progressive change, associated Avith slowly de- 
veloping and maintained hypertrophy of the myocardium in re- 
sponse to an increased demand for work. 

As in the case of cardiac hypertrophy, so in the presence of 



476 



PHYSICAL DIAGNOSIS 



cardiac dilatation the contour of the heal^t varies with the type 
and the degree of dilatation. When dilatation involves all four 
chambers of the heart, the heart is roughly spherical in outline. 
When a single chamber or one side of the heart is dilated, the 
contour is correspondingly irregular. The right ventricle is anatom- 
ically liable to a greater degree of dilatation than is the left 
ventricle, and the right auricle to more than the left auricle. 

Physical Signs. — Left Ventricular Dilatation. — Upon inspection 
the cardiac impulse is observed to be displaced toward the left and 







■i- f ^ 
















y 



Fig. 175. — Aortic incompetence with hypertrophy and dilatation of left ventricle, 
the result of arteriosclerosis affecting the aortic valves. Note how the valves have 
been curled, thickened, and shortened, the edges of valves being a half inch below the 
upper points of attachment. The anterior coronary artery is shown, the lumen narrowed. 
(Reduced one-half.) (From Wariield.) 



downward, and is diffuse and frequently undulatory in character. 
Not infrequently a cardiac impulse cannot be defined upon inspec- 
tion in the late stage of dilatation of the left ventricle. 

Upon palpation the cardiac impulse is defined with difficulty, it 
possesses little lifting power, and in late cases it may be altogether 
impalpable. A visible diffuse cardiac impulse which is not readily 
palpable is of immense diagnostic significance. 



DISEASES OF THE MYOCARDIUM 477 

Upon percussion the transverse dullness of the heart is extended 
toward the left and downward to a degree which is commensurate 
with the dilatation of the left ventricle. 

Auscultation of the apical area reveals a marked diminution in 
the muscular element of the first sound of the heart which is brief, 
of high pitch, and of a valvular quality closely approaching that 
of the normal second sound of the heart. Similarly the aortic 
second sound at the right second interspace is diminished in in- 
tensity, in striking contrast to the coincident accentuation of the 
second sound at the pulmonic area. A soft blowing systolic_mur- 
mur of relative paitral regurgitation is frequently audible at the 
apex and the aortic area is apt to be the site of a systolic or di- 
astolic murmur due to disease of the aortic valve. Reduplication 
of the first or second sound of the heart is frequently encountered 
and the gallop-rhythm of Potain is occasionally to be elicited. 

Right Ventricular Hypertrophy. — Inspection of the precordia 
in the presence of right ventricular dilatation usually re- 
veals a very diffuse and undulatory cardiac impulse, which occupies 
a position along the left sternal border, in the upper epigastrium, 
or extending to the right of the sternum. 

Palpation reveals the slapping character of the contraction of 
the dilated ventricle, which is in marked contrast to the powerful 
thrusting movement of the chamber in the presence of right ven- 
tricular hypertrophy. Bimanual palpation of the liver at this 
time will frequently elicit a systolic pulsation of this organ, occur- 
ring as the result of tricuspid regurgitation. 

Upon percussion it is usually possible to demonstrate a minor 
displacement of the cardiac outline toward the left but not down- 
ward; but the principal alteration in the cardiac outline is ex- 
tension of the dullness far to the right of the sternum, where it 
encroaches upon the normal pulmonary resonance of Ebstein's 
cardiohepatic angle. 

Percussion of the pulmonary bases usually elicits dullness due to 
pulmonary edema; and delimitation of the areas of hepatic and 
splenic dullness reveals an extension of dullness due to chronic 
passive congestion of these organs. 

Auscultation reveals enfeeblement of both sounds of the heart 
at the apex with diminution in the muscular element of the first 
sound, which approaches the valvular quality of the normal 
second sound of the heart. The pulmonic second sound at the base 
is markedly enfeebled. The soft and blowing murmur of relative 
tricuspid insufficiency is frequently audible at the tricuspid area. 



478 PHYSICAL DIAGNOSIS 

■ » 

Auricular Dilatation. — Dilatation of the left auricle affords few 
physical manifestations of its presence owing to the deep location 
of this chamber of the heart. It may be possible to demonstrate an 
extension of cardiac dullness to the left in the second left inter- 
costal space, and a visible impulse is occasionally perceptible in the 
same area. 

Right auricular dilatation is manifested by extension of the area 
of cardiac dullness toward the right in the second and third right 
intercostal spaces, and a visible pulsation in the same area. 

Diagnosis. — Cardiac dilatation is readily recognized by the 
character of the heart sounds, the increased extent of the area of 
cardiac dullness, the diffuse and undulatory cardiac impulse, 
which is displaced from its normal site, and the signs of systemic 
venous engorgement. 

Differential Diagnosis. — The enlarged heart of cardiac hyper- 
trophy is differentiated from cardiac dilatation by the strong and 
heaving cardiac impulse, which is clearly visible and is displaced 
from its normal site, the accentuated second sounds of the heart, 
the full and regular pulse, and the absence of signs of venous en- 
gorgement. 

The differential points between cardiac dilatation and pericardi- 
tis with effusion have been described under the latter disease. 

Increased dullness to the left of the heart which is due to consoli- 
dation of the left lung is differentiated by the presence of bronchial 
breathing and rales over the area of pulmonary disease. 

The area of cardiac dullness may also be extended by crowding 
forward of the heart by the growth of a mediastinal tumor; but 
these tumors produce pressure symptoms which are more pro- 
nounced than any which are produced by enlargement of the heart. 

Encysted pleurisy may be confused with cardiac dilatation by 
broadening the area of dullness around and adjacent to the heart ; 
but here there is usually the friction sound, and the heart sounds 
are not altered, and there are no signs of venous engorgement as in 
the case of cardiac failure. 

The presence of hypertrophic emphysema, by the interposition of 
the anterior borders of the lungs between the heart and chest wall, 
may effectually mask the cardiac enlargement, and require careful 
percussion to bring out the increase in the size of the organ. 

CONGENITAL HEART DISEASE 

Clinical Pathology. — Pulmonary stenosis is the most frequent 
and clinically the most important of the congenital lesions of the 



( 



DISEASES OF THE MYOCARDIUM 



479 



heart. The stenosis may be complete, the orifice of the vessel 
being closed by a fibrous membrane, or may permit all gradations 
of patency. In addition to obstruction at the valve, there may 
be narrowing of the conus arteriosus of the right ventricle, or the 
pulmonary artery may be congenitally narrow beyond the valvu- 
lar opening. 

The second most common congenital lesion of the heart is the 
patent foramen ovale, which normally closes during the first week 
of extrauterine life, but which may remain partially open to 
adult life in fourteen per cent of persons. 




Fig. 176. — Reptilian heart. (From Delafield and Prudden.) 



The interauricular septum may be found absent, resulting in 
the reptilian heart or cor triloculare. In other instances both the 
interauricular and interventricular septa are absent, the heart 
consisting of only two chambers, the cor bioculare. 

In a certain number of cases the ductus arteriosus, which usu- 
ally closes during the first month of extrauterine life, remains 
patent to give rise to signs of congenital heart disease. 

Congenital lesions of the aortic, mitral, and tricuspid valves 



480 PHYSICAL DIAGNOSIS 

are infreqiientlj' encountered. At the various valves of the heart, 
there may be supernumerary cusps or a diminution of the number 
of cusps, or adhesions between them, or merely a button-hole slit 
in a membrane closing an orifice. 

In certain unusual cases the aorta is found to arise from the 
right ventricle and the pulmonary artery from the left ventricle; 
while in cases of visceral transposition the heart lies chiefly in 
the right half of the thorax. 

Physical Signs. — The physical signs of congenital heart disease 
are early apparent, the most striking sign being extreme blueness 
or cyanosis of the child. However, cyanosis may be absent in 
the presence of cardiac disease. The finger-tips are often clubbed, 
the so-called Hippocratic fingers. Dyspnea is invariably present. 

As pulmonary stenosis is the most frequently underlying lesion, 
there is in most cases a systolic blowing murmur to the left of 
the sternum in the pulmonic area, with signs of hypertrophy of 
the right ventricle. On the other hand, a patent ductus arterio- 
sus yields a rather prolonged, systolic murmur in the same area 
which is, however, more distinctly audible in the third left inter- 
space. 

Diagnosis. — A diagnosis of congenital heart disease can be 
readily made in many cases on the extreme cyanosis, dyspnea, 
clubbed fingers, and loud blowing murmurs. However, it is often 
very difficult to say with certainty just what the underlying 
lesion is, as the signs are often confusing and frequently two 
conditions coexist. 

The murmurs of congenital disease are very difficult to differ- 
entiate from functional murmurs in anemic children; but it 
should be borne in mind in this connection that functional mur- 
murs are not transmitted and do not produce alterations in the 
myocardium. From acquired heart disease, congenital disease is 
usually differentiated by the fact that it is present from birth, 
the child from birth having been blue (morbus CEeruleus) ; that 
the child is usually under two years of age, at which time ac- 
quired lesions are practically unknown; and that the murmurs 
are atypical in location and transmission. 

ANEURYSM OF THE AORTA 

Clinical Pathology. — In the induction of aneurysm of the aorta 
two factors are interactive to produce the dilatation and partial 
rupture of the arterial coats ; namely, disease of the vessel wall in 



DISEASES OF THE MYOCARDIUM 481 

the form of atheroma, and strain exerted upon the vessel wall 
through hypertension in the greater circulation. Disease of the 
vessel wall arises through the prolonged action of the toxins of 
the acute infectious fevers, gout, and chronic mineral intoxica- 
tions, and preeminent among these predisposing factors ranks 
syphilis. 

The disease is most apt to attack male subjects during the 
third and fourth decades of life, the age at which arterial pres- 
sure is apt to be heightened by laborious occupations and when 
beginning atheroma is not infrequent. The disease is prone to 
develop in persons following laborious occupations in which the 
heart is repeatedly subjected to strain. 

Aortic aneurysm is most frequently a solitary lesion, although 
multiple aneurysmal dilatations of the vessel are encountered. 
The dilatation may assume the form of a fusiform enlargement 
of the lumen of the vessel, or it may take the form of a saccular 
dilatation. The site of solitary aneurysm may be the ascending 
aortic arch, the transverse arch of the aorta, the descending 
aortic arch, the descending thoracic aorta, or the abdominal 
aorta. 

The saccular aneurysm of the ascending arch of the aorta usually 
develops upon the convexity of the arch above the pericardium 
and extends toward the right and forward, reaching the anterior 
chest wall in the second or third right intercostal space. In this 
situation the aneurysm may cause compression of the superior vena 
cava with resulting engorgement of the cervical veins, or it may 
compress the subclavian vein alone, producing venous stasis and 
edema of the right arm. With less frequency the aneurysm de- 
velops upon the concavity of the ascending aorta, producing an 
area of dullness along the right sternal border, and occasionally the 
aneurysm is situated in the proximal portion of this part of the 
aorta and is enveloped by the pericardium. Aneurysm of this 
portion of the aorta displaces the heart downward and toward the 
left ; and the usual termination of the disease is by rupture into 
the pleural cavity, the pericardium, or rarely into the superior 
vena cava. 

Aneurysm of the transverse arch of the aorta in the majority of 
cases springs from the posterior aspect of the vessel, with less 
frequency from the anterior wall, and with least frequency from 
the concavity of the arch. Posterior aneurysm of the aortic arch 
extends backward toward the vertebral column, resulting in pres- 
sure symptoms arising from compression of the trachea and esopha- 



482 PHYSICAL DIAGNOSIS 

gus, and producing pupillary disturbances alid paroxysmal cough 
from compression of the recurrent laryngeal nerve, which hooks 
around this portion of the vessel. Aneurysm springing from the 
anterior wall of the aortic arch progresses forward and erodes the 
sternum, causing a tumor which points toward the right sternal 
margin more often than toward the left of the median line. Aneu- 
rysm springing from the concavity of the arch progresses down- 
ward, with compression of the left bronchus, and recurrent laryn- 
geal nerve disturbances. 

Aneurysm of the descending aortic arch usually springs from the 
posterior aspect of the vessel and progresses backward and toward 
the left, causing erosion of the thoracic vertebrae between the third 
and sixth dorsal segments. Pressure is exerted upon the roots of 
the spinal nerves, the left bronchus, or the root of the lung; and 
rupture may occur into the left bronchus, the trachea, or the 
esophagus. 

Aneurj^sm of the descending thoracic aorta usually springs from 
the inferior portion of the vessel, just above the diaphragm, and 
the sac develops in contact with the lower thoracic vertebrge. The 
bodies of the lower thoracic vertebrge are eroded and dysphagia is 
a common symptom from compression of the esophagus. 

Aneurysm of the abdominal aorta, which is relatively less fre- 
quently encountered than is aneurysm of the thoracic portion of 
the vessel, usually springs from the ventral aspect of the aorta 
immediately below the diaphragm in the vicinity of the origin of 
the celiac axis, whence the tumor progresses forward to produce 
bulging of the epigastrium or left hypochondriac region. With 
less frequency the aneurysm takes origin from the posterior aspect 
of the abdominal aorta and progresses backward and erodes the 
bodies of the vertebrae. Rupture may occur into the retroperitoneal 
tissues, or into the peritoneal cavity, and rarely a communication 
is established with the inferior vena cava. 

The course of the disease is insidious and progressive, resulting 
in rupture of the sac in 75 per cent of the cases. In some in- 
stances the disease remains latent for a prolonged period, but 
with the ever-increasing dimensions of the tumor, pressure symp- 
toms eventually come into the foreground of the clinical picture. 
Of these dyspnea is often one of the most urgent. This occurs 
from compression of the right heart, the trachea, bronchi, pulmo- 
nary artery or vagus nerve, as the case may prove. Cough is 
frequently excessive arising partially as a result of recurrent 
laryngeal nerve compression, and frequently from interference 



DISEASES OF THE MYOCARDIUM 483 

with the pulmonary circulation with the induction of chronic 
bronchial inflammation. Dysphagia is apt to arise from compres- 
sion of the esophagus or from compression of the recurrent 
laryngeal nerve producing spasm of the esophagus. Erosion of 
the sternum or of the bodies of the vertebrae is attended by pain 
of a dull and boring character, and compression of the vagus 
nerves is followed by pseudoanginal attacks. 

Physical Signs. — Inspection. — In the presence of aneurysm of 
the ascending or transverse arch of the aorta inspection of the 
anterior surface of the thorax by oblique illumination frequently 
reveals the presence of a systolic pulsation in the second and third 
intercostal spaces adjacent to the sternum or in the suprasternal 
notch. In the presence of aneurysm of the descending aortic arch 
a similar pulsation is frequently to be encountered in the left 
interscapular region at the level of the scapular spine. In ad- 
vanced cases of aneurysm of the arch there may be a visible pro- 
trusion of the thoracic wall in the region of the manubrium sterni 
which exhibits true expansile pulsation during ventricular systole. 
The cardiac impulse frequently occupies a position lower and 
farther to the left than in the normal subject, as a result of dis- 
placement of the heart by the growth of the aneurysm. 

The tracheal tug of Oliver may be elicited in many cases of 
aneurysm of the aortic arch and should always be sought for by 
the examiner. 

Palpation. — Palpation with the palm of the hand gently applied 
to the pulsating area is useful in demonstrating true expansile pul- 
sation and in estimating the resistance which is offered by the 
underlying structures to the impact of the blood stream. Fre- 
quently the wall covering the pulsation is quite resistant, while in 
other instances of perforating aneurysm the pulsating area is soft 
and readily compressible. 

The pulse in aortic aneurysm is of service in estimating the loca- 
tion of the lesion. In the presence of aneurysm of the ascending 
aortic arch there is no asymmetry in the two radial pulses. When, 
however, the aneurysm involves the arch distal to the origin of the 
innominate artery, the left radial pulse is delayed, resulting in 
asymmetry of the radial pulse upon the two sides of the body. 

Percussion. — In the presence of extensive aneurysmal dilatation 
of the ascending aortic arch there is a demonstrable area of dullness 
extending to the right of the area of vascular dullness in the second 
and third intercostal spaces to the right of the sternum. In the 
cases of aneurysm of the transverse arch there is an extensive 



484 PHYSICAL DIAGNOSIS 

area of dullness extending to the right and to the left of the man- 
ubrium sterni ; and in the presence of aneurysm of the descending 
arch there is a demonstrable area of dullness in the left inter- 
scapular region at the level of the spine of the scapula. Small 
aneurysmal dilatations of the aorta do not, however, appreciably 
modify the percussion note of the thorax. 

Auscultation. — Auscultation of the thorax overlying an aortic 
aneurysm is apt to reveal the presence of a systolic murmur; but 
the detection of a murmur is not sufficient ground for a diagnosis 
of aneurysm. More important than the murmur in a suspected 
case is the presence of a loud, ringing and accentuated aortic second 
sound, a sign which is rarely absent in the presence of aneurysm of 
the aortic arch. Occasionally this accentuated sound is found re- 
placed by a diastolic murmur at the aortic valve in cases which are 
unquestionably aneurysmal. A systolic murmur is frequently ap- 
preciable in the carotids in the presence of aneurysm of the arch, 
but a similar transmitted murmur attends organic stenosis at the 
aortic valve. 

The symptoms and physical signs emanating from aneurysm of 
the abdominal aorta are in no wise as distinctive as is the case 
with aneurysm of the thoracic aorta. There is usually dull and 
boring pain, and frequently a visible pulsation of the epigastric 
region. When such a pulsation is encountered the patient should 
be examined in the knee-chest posture in order to cause any intra- 
abdominal tumor to fall away from the subjacent aorta. Care 
should also be taken to exclude the systolic pulsation of the epi- 
gastrium which attends massive right ventricular hypertrophy. 

Diagnosis. — The cardinal signs of aortic aneurysm comprise 
dullness at the base of the heart, extending to the right or left 
of the sternum, dullness in the left interscapular region at the 
level of the scapular spine, pupillary changes, and pressure symp- 
toms, occurring in a subject of a laborious occupation or suffer- 
ing with syphilis. Later in the evolution of the disease boring 
pain becomes a marked feature of the case with cough, cardiac 
disturbances, asymmetry of the pulses and visible tumor with 
true expansile pulsation. Fluoroscopy is of aid in establishing 
the diagnosis and in localizing the site of the lesion. 



PART 11. THE ABDOMEN 



SECTION I 
GENERAL EXAMINATION OF THE ABDOMEN 



CHAPTER XX 

CLINICAL ANATOMY OF THE ABDOMEN 

The abdomen, the portion of the trnnk which is limited upon the 
surface of the body by the ensiform cartilage and the costal arch 
superiorly and by the pubic crest and Poupart's ligaments in- 
feriorly, presents an irregularly oval contour, the shape varying, 
however, with the age and the sex of the subject. Thus, the abdomen 
of the child is roughly conical with the apex directed inferiorly; 
while in the adult female subject, owing to the unusual breadth of 
the pelvis in this sex, it is roughly conical with the apex directed 
superiorly ; whereas in the case of the adult male subject the abdo- 
men is oval or barrel-shaped, with a moderate anteroposterior flat- 
tening. 

The abdominal cavity is limited superiorly by the inferior aspect 
of the diaphragm, and inferiorly by the levator ani, assisted by the 
coccygeus, these two muscles constituting the pelvic diaphragm. 
The more roomy upper portion of the abdominal cavity, situated 
above the brim of the pelvis, is termed the abdomen proper, while 
the smaller portion of the cavity situated below the pelvic inlet is 
termed the pelvis. 

The abdominal cavity is not limited superiorly hy the lower bor- 
der of the costal arch, which forms its upper boundary upon the 
surface of the abdomen, but by the vault of the diaphragm, extend- 
ing upward into the bony thorax for a considerable distance. Upon 
the right side its superior limit is on a level with the upper border 
of the fifth rib in the midclavicular line ; while upon the left side 
of the body its superior limit is approximately one-half inch lower 
in the same line. 

The abdominal wall is composed largely of muscular and soft 

485 



486 PHYSICAL DIAGNOSIS 

structures, reinforced in certain regions by bony structures. An- 
teriorly and laterally the wall is formed of the abdominal muscles, 
the lower ribs and iliac bones. Posteriorly it is formed by the mus- 
cles of the posterior abdominal wall, the quadratus lumborum and 
psoas upon either side, and in the median line by the vertebral col- 
umn. The anterior abdominal wall and the lateral walls between 
the last rib and the iliac crest are devoid of bony support and are 
subject to distention and retraction, depending upon the state of 
the abdominal contents. 

Within the abdominal cavity the liver occupies the upper right 
quadrant of the cavity, sheltered largely beneath the inferior right 
costal margin, but extending also into the subcostal angle in the 
epigastric region. The spleen occupies a deep position in the upper 
left quadrant, sheltered by the ninth, tenth, and eleventh ribs and 
in apposition with the fundus of the stomach. The stomach occu- 
pies a position in the superior portion of the abdominal cavity, be- 
tween the liver and the spleen ; and from the greater curvature of 
the stomach the great omentum descends for a variable distance 
and covers the coils of the small intestine. The coils of the small 
intestine occupy the central and inferior portions of the abdominal 
cavity, slightly overlapping the ascending and descending colon in 
the lumbar regions. The large intestine envelops the small intes- 
tine in the form of a frame with an inferior concavity upon three 
sides of the abdominal cavity. The urinary bladder occupies the 
anterior portion of the pelvis ; and, if it is in a state of distention, 
rises above the pubic crest to mount into the hypogastric region. 
The rectum occupies the posterior portion of the pelvis, lying in 
the concavity of the sacrum. 

ANATOMICAL LANDMARKS OF THE ABDOMEN 

At the superior limit of the anterior abdominal surface in the 
median line is the ensiform cartilage, with the costal arch descend- 
ing from it upon either side of the abdomen. The anterior ex- 
tremities of the fifth, sixth, seventh, eighth, ninth, and tenth costal 
cartilages are palpable ; and, in the case of thin subjects with 
relaxation of the abdominal walls, the free extremities of the 
eleventh and twelfth ribs as well may be palpated. 

At the inferior limit of the abdomen the sympJiysis pubis with its 
pubic spines is encountered, and extending from them in a direc- 
tion outward and obliquely upward, one encounters Poupart's liga- 
ment upon either side of the abdomen. 



CLINICAL ANATOMY OF THE ABDOMEN 



487 



In the inferior and lateral regions the iliac crest, terminating 
anteriorly in the anterior superior iliac spine is encountered, the 
latter remaining plainly palpable even in obese subjects. 

In the lower central reo'ion of the abdominal surface the um'bili- 




Fig. 177. — Anatomical landmarks of abdomen: 



A. Lineae transversae. B. Costal arch. C. Linea semilunaris. D. Anterior supe- 
rior iliac spine. B. Symphysis pubis. F. Commencement of abdominal aorta. G. Origin 
of celiac axis. H. Linea alba. I. Origin of superior mesenteric artery. J. Origin of 
inferior mesenteric artery. K. Bifurcation of aorta. L. Poupart's ligament. 



488 



PHYSICAL DIAGNOSIS 



cus is noted. It corresponds to the level of the disc between the 
third and fourth lumbar vertebrae. 

The linea alba extends in the median line from the ensiform 
cartilage to the symphysis pubis. It is indicated by a slight groove 
in the median line of the abdomen above the level of the umbilicus, 




S 




'^ H 



h 




Fig. 178. — The abdominal surface with the rib margins and the iliac crests outlined. 

(From Crossen.) 

and by a line of hair or of brown pigment, the linea nigra, below 
the umbilicus. 

The linea semilunaris^ upon either side of the. abdomen, extends 
with a slight convexity outward from the junction of the tip of 
the ninth costal cartilage with the external border of the rectus 



CLINICAL ANATOMY OF THE ABDOMEN 489 

muscle to the pubic spine. It corresponds accurately to the external 
limit of the sheath of the rectus muscle. 

Linece transversce are to be noted in subjects of good muscular 
development. They are transverse constrictions in the rectus mus- 
cles. They are three in number, as a rule, although a fourth may 
sometimes be encountered. One constriction is located at the level 
of the ensiform cartilage, another at the level of the umbilicus, and 
a third constriction midway between these two. "When a fourth 
constriction is present, it is located midway between the umbilicus 
and the symphysis pubis. 

Cutaneous flexion folds are encountered in obese subjects. They 
are usually two in number, one at the level of the umbilicus and the 
other just above the symphysis pubis. 

TOPOGRAPHICAL ANATOMY 

The course of the abdominal aorta corresponds to a vertical line 
upon the anterior surface of the abdomen extending from a point 
a little to the left of the ensiform process downward to a point 
three-fourths of an inch below and a little to the left of the umbili- 
cus, where the vessel bifurcates to form the common iliac arteries. 
Upon this line the celiac axis arises from the abdominal aorta at a 
point four and one-half to five inches above the umbilicus; the 
superior mesenteric artery arises at a point four inches above the 
umbilicus; the renal artery arises three and one-half inches above 
the umbilicus; and the inferior mesenteric artery arises one inch 
above the level of the umbilicus. 

The course of the common iliac and external iliac arteries corre- 
sponds to a line drawn from the point of bifurcation of the abdom- 
inal aorta to a point midway between the anterior superior iliac 
spine and the symphysis pubis. 

The course of the deep epigastric artery is represented by a line 
drawn from the midpoint of Poupart's ligament upward and 
inward to the umbilicus. 

The course of the inferior vena cava is represented by a vertical 
line drawn along the line representing the course of the abdominal 
aorta, a little distance to the right side of this line. 

The common and external iliac veins are indicated by lines upon 
the abdominal surface slightly below and to the right of and corre- 
sponding in direction to the lines of the arteries of the same name. 

The topographical anatomy of the various abdominal organs 
is described in the sections dealing with the respective organs. 



490 



PHYSICAL DIAGNOSIS 



TOPOGRAPHICAL REGIONS OF THE ABDOMEN 

For purposes of description and in order to facilitate the accu- 
rate localization of pathologic conditions arising within the ab- 
dominal cavity, the abdomen is divided into certain arbitrary 
regions by means of vertical and horizontal lines, or the division 
of the abdominal cavity may be established by the utilization of 
the bony landmarks as detailed in a subsequent paragraph. 




Fig. 179. — Another abdominal surface, with the ribs and crests outlined. This patient 
is rather stout. Notice how much the landmarks differ from those in Fig. 178. (From 
Crossen.) 



CLINICAL ANATOMY OF THE ABDOMEN 



491 



A very useful division of the abdominal cavity is by the erec- 
tion of two vertical and two horizontal lines upon the anterior 
abdominal surface, thus dividing the abdominal cavity into nine 
regions. In this method of division of the abdominal caAdty, the 
superior horizontal line, the suhcostal line, is drawn around the 
body at the level of the most dependent portion of the tenth costal 
cartilage. The inferior horizontal line, the intertuljercular line, 
encircles the trunk at the level of the tubercle which is palpable 





Fig. 180. — The usual anatomic division of the abdomen into nine regions by two 
transverse lines and two vertical lines. The upper transverse line is at the level of the 
cartilages of the tenth ribs, and the lower with the highest points of the iliac crests. The 
two parallel vertical lines pass through the cartilages of the eighth ribs and the middle 
of Poupart's ligaments. (From Crossen.) 



upon the iliac crest approximately two inches behind the anterior 
superior iliac spine. The two vertical lines, the mid-Poupart lines, 
are erected from the midpoint of Poupart's ligament upon either 
side, blending superiorly with the midclavicular lines of the thorax. 
Through the medium of these arbitrary lines, the abdominal 



492 PHYSICAL DIAGNOSIS 

cavity is divided into nine regions. The ep'iT/astric region, bounded 
inferiorly by the subcostal line, and superiorly and laterally by 
the line of the costal arch, overlies the stomach, duodenum, liver, 
gall bladder, pancreas, and portions of the two kidneys. 

The left hypochondriac region, limited inferiorly by the sub- 
costal line and internally by the line of the left costal arch, over- 
lies the fundus of the stomach, the spleen, and the splenic flexure 
of the colon. 

The right hypochondriac region, limited inferiorly by the sub- 
costal line and internally by the line of the right costal arch, over- 
lies the portion of the abdominal cavity which is occupied by the 
liver and right kidney. 

The nmhilical region, limited superiorly by the subcostal line, 
inferiorly by the intertubercular line, and laterally by the right 
and left mid-Poupart lines, overlies the coils of the small intestine, 
the mesentery, the great omentum, a portion of the two kidneys, 
and of the transverse colon. 

The left Innihar region, bounded superiorly by the subcostal line, 
inferiorly by the intertubercular line, and internally by the left 
mid-Poupart line, overlies the left kidney, the descending colon, and 
some coils of the small intestine. 

The right lumbar region, limited superiorly by the subcostal line, 
inferiorly by the intertubercular line, and internally by the right 
mid-Poupart line, overlies a portion of the right kidney, of the 
ascending colon, and coils of the small intestine. 

The hypogastric region, lying below the intertubercular line and 
limited laterally by the mid-Poupart lines, and inferiorly by the 
pubic symphysis, overlies the distended bladder, some coils of the 
small intestine, a portion of the sigmoid flexure, the cecum, occa- 
sionally the vermiform appendix, and the pregnant uterus. 

The left iliac region, limited superiorly by the intertubercular 
line, inferiorly by Poupart's ligament, and internally by the left 
mid-Poupart line, overlies the sigmoid flexure of the colon. 

The right iliac region, limited by the intertubercular line, the 
right mid-Poupart line, and Poupart's ligament, overlies the cecum 
and usually the vermiform appendix. 

Instead of the division of the abdominal cavity into nine regions 
by means of two horizontal and two vertical lines, the cavity may be 
divided into four regions, or quadrants, through the medium of a 
horizontal and a vertical line passing through the umbilicus. In 
this method of subdivision the four regions are termed, respectively, 



CLINICAL ANATOMY OF THE ABDOMEN 



493 



the right upper quadrant, the left upper quadrant, the right lower 
quadrant, and the left lower quadrant, of the abdomen. 

The right upper quadrant of the abdomen overlies the right lobe 
of the liver with the gall bladder, the hepatic flexure and the 
proximal portion of the transverse colon, the pylorus, the first and 
second portions of the duodenum and the head of the pancreas, and 
more deeply in this region, the superior half of the right kidney. 

The left upper quadrant of the abdomen overlies the left lobe of 





'^•'> .. 



Fig. 181. — The abdominal surface divided into quadrants. (From Crossen.) 

the liver, the stomach, the distal half of the transverse colon with 
the splenic flexure, the larger portion of the pancreas, the superior 
half of the left kidney, and the spleen. 

The right lower quadrant of the abdomen overlies the cecum with 
the vermiform appendix, the ascending colon, the inferior half of 
the right kidney, the right fallopian tube and ovary, together with 
portions of the bladder and the uterus. 



494 



PHYSICAL DIAGNOSIS 



The left lower quadrant of the abdomen "Qverlies the descending 
colon and sigmoid flexure, a portion of the inferior half of the left 
kidney, coils of the small intestine, the left fallopian tube and ovary, 
and a portion of the bladder and of the uterus. 

A very convenient subdivision of the abdominal cavity is that 
devised by Crossen, in which the natural landmarks of the abdomen 











ir 



C3 



^'imif 



4 



Fig. 182. — Another abdomen divided with the circle and short horizontal lines, and 
showing the names on the primary regions. The area within the circle carries the usual 
designation, "umbilical region." (From Crossen.) 



are utilized, the only artificial lines employed being one encircling 
the umbilicus, and a horizontal line drawn from either side of the 
circle. By this method the abdomen is subdivided into regions 
which are respectively designated a right upper, left upper, central 
upper, right lower, left lower, central lower, umbilical right lumbar, 
and left lumbar. 



CHAPTER XXI 
INSPECTION OF THE ABDOMEN 

Technic. — During inspection of the abdomen the patient should 
in the first instance assume the dorsal decubitus, the position in 
bed or upon the examining table being absolutely symmetrical 
and free from undue tension of the abdominal muscles. The sub- 
ject should be covered with a sheet which may be turned down, 
exposing the abdomen freely to a short distance above the pubic 
symphysis. The examiner should in the first place stand beside 
the abdomen and inspect its surface first by direct illumination 
and afterward by oblique illumination, the latter frequently re- 
vealing slight pulsations, protrusions or vermicular movements 
which escaped detection during the examination by direct illumi- 
nation. The examiner should then assume, consecutively, posi- 
tions near the feet and near the head of the subject and should 
inspect the abdominal wall from these two positions. 

For the purpose of detecting certain phenomena such as the 
vermicular movements of visible peristalsis and abdominal sag- 
ging due to visceroptosis, the abdomen should in addition be 
inspected with the subject in the standing posture. Finally, in 
certain instances it is desirable to examine the patient in the 
genupectoral posture, a position which permits movable tumors 
of the abdominal viscera to fall forward and to become more 
clearly visible upon inspection of the abdominal surface. 

THE SKIN OF THE ABDOMEN 

The integument of the abdomen is lax and loose in the presence 
of emaciation from chronic wasting disease, and is tense and 
glistening in the presence of abdominal distention from ascites, 
pregnancy, or increased intraabdominal tension attending the 
development of a large intraabdominal tumor. Whitish or silvery 
stridae, li7icB alhicantes, distributed over the lower portion of the 
abdomen and the upper portions of the thighs are indicative of 
former abdominal distention, whether from tumor, ascites, or preg- 
nancy. 

Scars upon the abdomen may result from former surgical opera- 

495 



496 PHYSICAL DIAGNOSIS 

tions, from trauma, or from the eruption of syphilis or other cutane- 
ous disease. A scar in the groin is suggestive of suppuration of an 
inguinal gland, which has opened spontaneously or has been opened 
by the surgeon. 

The Imea nigra, a line of brown pigment in the median line of 
the abdomen below the umbilicus, accompanies pregnancy and 
chronic abdominal distention from other cause. 

The abdomen is the usual site of the cutaneous eruption of 
typhoid fever, the rose spot of this disease. These spots are small, 
discrete, hyperemic, slightly elevated papules, which readily disap- 
pear upon pressure. In certain instances the papule is surmounted 
by a small vesicle. They are not limited to the abdomen, though 
most frequently encountered in this locality ; but may appear upon 
the back, the arms, or the thighs. The rose spots appear in succes- 
sive crops, disappearing in two or three days, sometimes leaving a 
brownish stain. 

During pregnancy the abdominal skin occasionally exhibits the 
brownish areas of chloasma. 

ENLARGEMENT OF THE SUPERFICIAL VEINS 
OF THE ABDOMEN 

In the presence of portal obstruction, there is present upon the 
abdominal wall a series of distended superficial veins extending 
outward from the umbilicus in a radial manner, constituting the 
caput meduscE. A distention of the superficial veins over the abdo- 
men, communicating with similarly distended veins over the thorax, 
is indicative of portal vein obstruction by hepatic cirrhosis or 
tumor, chronic ascites, or pressure exercised upon the inferior 
or superior vena cava by abdominal or mediastinal tumor. The di- 
rection of the blood current in the distended vein is an index to the 
site of the obstruction. If, upon compression of the vein, it is found 
that the direction of the blood current is upward, the obstruction is 
in the portal vein or inferior vena cava ; whereas, if the current is 
directed downward, the obstruction is situated in the course of the 
superior vena cava. The venous tortuosity under these circum- 
stances is an evidence of the effort at the establishment of collateral 
circulation in the presence of obstruction of the usual venous 
channels. 

THE UMBILICUS 

The umbilicus should be examined for protrusion, retraction, 
skin eruptions, and inflammation. A protruding umbilicus is 



INSPECTION OF THE ABDOMEN 497 

noted in umbilical hernia, during the latter months of pregnancy, 
in the presence of portal vein obstruction, ascites, or abdominal 
distention due to the development of a large intraabdominal 
tumor. In the obese subject on the contrary the umbilicus is 
markedly retracted. 




Fig. 183. — ^Establishment of collateral circulation in portal vein obstruction and mediastinal 

tumor. (Eisendrath.) 

/, internal mammary veins; 2, anterior intercostal veins; 5, posterior intercostal veins; 
4, radicles of 2; 5, subclavian vein; 6, deep epigastric vein; 7, external iliac vein; 5, super- 
ficial circumflex iliac vein; 9, internal saphenous vein; ?o, caput medusae. 



498 



PHYSICAL DIAGNOSIS 



ENLARGED GLANDS 

The glands in the groin are enlarged as a result of venereal 
infection or localized nonspecific inflammation resulting from 
abrasions about the external genitalia or of the lower extremities. 
The character of the adenopathy whether hard and discrete or 
soft and fluctuating with matting of the glands, should be de- 




Fig. 184. 



-Abdominal arteries in a case of double iliac thrombosis of typhoid origin. 
CWoolley, after Thayer.) 



INSPECTION OF THE ABDOMEN 



499 




Fig. 185. — A small umbilical hernia, with a relaxed abdominal wall. (Crossen, after Hirst.) 

terminecl with the view of the differentiation of luetic and chan- 
croidal adenopathies. 



VISIBLE PERISTALSIS 

The peristaltic movements of the stomach, small intestine, or 
large intestine at times become visible as a vermicular movement 
upon the anterior abdominal wall. In its exaggerated form it is 
indicative of obstruction located at the pylorus, at some point in 
the course of the small intestine, or in the colon. 

The peristaltic movement of the stomach is visible under these 
circumstances in the upper portion of the abdomen, pursuing a 




Fig. 186. — A large ventral hernia at the site of an operation scar. (Crossen, after Hirst.) 



500 



PHYSICAL DIAGNOSIS 



direction from left to right and somewhat downward in the epi- 
gastric region. 

Visible peristalsis of the small intestine is chiefly confined to 
the umbilical region, whereas that occasioned by obstruction of 



fv.. 



/J 




f 




'-^ 



Fig. 187. — Stenosis in the vicinity of the splenic flexure. (Austin, after Nothnagel.) 

the large intestine is observed over the course of the colon. When 
it is not unduly pronounced, peristaltic movement of the ab- 
dominal wall may often be accentuated by applying a cold hand 
to the abdominal surface or by flicking the surface of the abdo- 
men with a towel which has been wet in cold water. When the 



INSPECTION OF THE ABDOMEN 501 

site of the obstruction is situated in the ileum just proximal to 
the ileocecal valve, the visible peristalsis assumes frequently a 
''ladder pattern," the waves lying one above the other in the 
umbilical region. 

Visible peristalsis observed in extremely emaciated patients 
with extremely thin abdominal walls, or in women in whom re- 
peated pregnancy has caused a diastasis of the rectus muscles, 
possesses no diagnostic significance. 

ABOLITION OF THE RESPIRATORY MOVEMENTS OF THE 

ABDOMEN 

Fixation of the abdominal Avail with inhibition or abolition of 
the respiratory movements is indicative of pain arising within the 
abdominal cavity with the respiratory excursion of its walls, 
which is not infrequently due to acute peritonitis. 

VARIATIONS IN THE CONTOUR OF THE ABDOMEN 

The normal abdomen is symmetrical with a moderate degree of 
anteroposterior flattening in the male subject. The walls are of 
uniform tension, and it presents a moderate bulging of the infe- 
rior regions in the female subject. The umbilicus of the normal 
abdomen is neither unduly depressed nor protruding. 

Variations in the contour of the abdomen may be symmetrical 
or asymmetrical. Symmetrical enlargement of the abdomen is 
encountered in the presence of obesity, pregnancy, intestinal 
meteorism, ascites, and in the presence of visceroptosis. Sym- 
metrical retraction of the abdomen is encountered in conditions 
of emaciation depending upon cardiac or pyloric stenosis, or the 
moribund state. 

OBESITY 

In the obese subject the abdomen is symmetrically enlarged; 
the cutaneous flexion folds are accentuated; the umbilicus is 
unduly depressed; and the inferior regions of the abdomen are 
pendulous, encroaching to a variable extent upon the thighs and 
the pubes. 

PREGNANCY 

The abdominal enlargement accompanying pregnancy is pro- 
gressive, increasing gradually as the uterus rises out of the pelvis. 



502 



PHYSICAL DIAGNOSIS 



and comes to occupy the abdominal cavity. In its fully developed 
state the umbilicus protrudes, the abdominal skin presents the 
linese albicantes of pregnancy, and the abdominal distention is 
accompanied by changes in the breasts and the positive signs of 



^- 



A 



^^^' 



/ 



/ 



Fig. 188. — Stenosis of the lower ileum from peritoneal adhesion. (Austin after Nothnagel.) 

pregnancy. The degree of abdominal distention is much more 
considerable in the case of multiparous v^omen than is the case 
with primiparse. 



IXSPECTIOX OF THE ABDOMEN 503 

METEORISM 

Meteorism or t3^mpanites produces symmetrical abdominal en- 
largement of transient duration, the abdominal walls being tense, 
smooth and shiny, affording upon percussion a distinctly tympan- 
itic note, which extends high up and decreases the area of normal 
dullness of the liver. The umbilicus is level with the adjacent 
abdominal surface or actually protrudes. 



< 




Fig. 189. — Xormal intestinal peristalsis. (Austin, after Xothnagel.) 

ASCITES 

The degree of abdominal enlargement accompanying ascites 
varies with the amount of fluid in the peritoneal cavity. With 
the development of the ascitic fluid there is a gradual and uni- 
form enlargement of the abdomen. The contour of the abdomen 
is characteristically altered, the anteroposterior diameter increas- 
ing with moderate flattening of the lateral regions. In the pres- 



504 



PHYSICAL DIAGNOSIS 



Fig. 190. — Median grooving of the abdominal wall where there is separation of the recti 
muscles. The woman is represented as lying on her back. (Crossen, after Webster.) 




Fig. 191. — Obesity. The most prominent feature in this case is the marked obesity — 
see Fig. 192. There is also a fibroid tumor of the uterus and a small amount of ascitic 
fluid. (From Crossen.) 



INSPECTION OF THE ABDOMEN 



505 



ence of an extensive effusion into the peritoneal cavity the 
abdominal skin is smooth and tense, and not infrequently it 
presents silvery strige. Enlarged, tortuous superficial veins are 
frequently in evidence. 

When the subject of ascites assumes the dorsal decubitus, the 
percussion note is tympanitic in the median line of the abdomen 
and is flat in the flanks, owing to the fact that the intestines float 
upward in the fluid, which gravitates to the dependent portions of 




Fig. 192. — Obesity. Patient standing. Same patient as shown in Fig. 191. Notice 
the thick roll of subcutaneous fat that drops down below the general contour of the 
abdomen. 



the abdominal cavity. When the subject is placed in the lateral 
decubitus, there is dullness upon the under side and tympany 
upon the superior side as a result of the same shifting of the in- 
testines with relation to the fluid. Finally, upon placing the 
subject in the genupectoral position, there is flatness in the um- 
bilical and hypogastric regions, with tympany in the flanks, 
which are occupied by the resonant intestinal coils. 



506 



PHYSICAL DIAGNOSIS 



VISCEROPTOSIS 

Ptosis of the abdominal organs produces characteristic altera- 
tions in the abdominal contour with the subject in the erect 
attitude. Thus, in the presence of gastroptosis, there is an abnor- 
mal flattening of the epigastric region with undue prominence 
of the umbilical region; whereas in the case of enteroptosis, the 



Fig. 193. — Obesity, mistaken for pregnancy by patient. (Crossen, after Williams.) 



Fig. 194. — Contour of the abdomen in pregnancy with patient recumbent. (Crossen, 

after I^dgar.) 



INSPECTION OF THE ABDOMEN 



507 



epigastric and umbilical regions of the abdomen are flattened, 
with marked bulging of the hypogastric and iliac regions, the 
general contour of the abdomen resembling that of a gourd. 



..^*^~ 



X 



Fig. 195. — Tympanites, mistaken for pregnancy by the patient. (Crossen, after I^dgar.) 




Fig. 196. — Extreme ascites. In the patient from which this photograph was taken, 
the abdomen was so distended with fluid that the wall was raised higher than the 
mesentery would permit the intestine to float, giving dullness about the umbilicus as well 
as elsewhere. The rise of the wall from below is rather abrupt. There is also edema of 
the wall, as shown by the persisting groove where the skirts were tied about the waist. 
(From Crossen.) 



508 



PHYSICAL DIAGNOSIS 




Fig. 197. — Showing the area of dullness in moderate ascites, with the patient lying on 
her back. (From Crossen.) 



^,. .,^#^^ ^' 




Fig.- 198. — Showing the reason for the disposition of the dull and resonant areas m a 
case of moderate ascites. (Crossen, after Butler.) 



.U- ti^' ' ^--^^'f 




Fig. 199. — Ascites. Representing the patient turned on one side. The fluid gravitates 
to the under side, leaving the upper flank resonant. (Crossen, after Butler.) 



INSPECTION OF THE ABDOMEN 



509 



ASYMMETRICAL VARIATIONS 

Local bulging of the epigastric and hypochondriac regions of 
the abdomen may be significant of distention of the stomach, or 
enlargement of the liver, gall bladder, or spleen. Bulging of the 
abdominal wall involving the upper lateral regions of the abdo- 
men and encroaching upon the umbilical region attends enlarge- 
ments of the kidneys. 

Undue prominence of the umbilical region alone occurs with 




200. — Indicating the area ol dullness in moderate ascites, with the patient standing. 
(From Crossen.) 



umbilical hernia, and in the case of the progressive enlargement 
of a neoplasm of the intestine. 

Local bulging of the abdominal wall confined to the hypo- 
gastric and iliac regions may be due to a distended urinary blad- 
der, a pregnant uterus, uterine myoma, or ovarian cyst. 

The differential points in regard to abdominal enlargement as 
a result of disease of the various abdominal viscera are discussed 
in connection with the special examination of the organ in ques- 
tion in subsequent sections. 



510 



PHYSICAL DIAGNOSIS 



ABDOMINAL RETRACTION 

In the presence of chronic wasting disease, during the course of 
prolonged diarrhea, and in the presence of stenosis of the cardiac 
or pyloric orifice of the stomach, the abdominal wall is retracted, 
the Dony landmarks standing out very prominently. The abdo- 
men appears to be ''scooped out" like a boat, the scaphoid abdomen. 




mrmt' .---^m^^ 



Fig. 201. — Indicating the area of dullness in a case of moderate ascites, with the patient 
turned on the left side. (From Crossen.) 




Fig. 202. — Abdominal enlargement due to ovarian cyst. 



CHAPTER XXII 

PALPATION, PERCUSSION, AUSCULTATION, AND MEN- 
SURATION OF ABDOMEN 

PALPATION 

Technic— During palpation of the abdomen the patient should 
assume the dorsal decubitus with the head slightly elevated by a 
small pillow and the knees drawn up and supported by a pillow, 
which relieves the tension of the abdominal wall. In bed-ridden 
subjects a similar state of abdominal relaxation may be attained 
by propping the patient's shoulders up with pillows and drawing 
up the knees and supporting them. Under certain circumstances 
it is desirable to palpate the abdomen with the patient in the 
knee-chest position. 

The patient having been placed in a natural and unconstrained 
attitude, he should be directed to refrain from the natural ten- 
dency to hold the breath during the examination. 

The hands of the examiner should be warm, as a cold hand 
applied to the surface of the bare abdomen will cause a local 
muscular rigidity which combats and frustrates the object of the 
examination. The examining hand should be first applied very 
gently to the abdominal surface with the palm down and fingers 
extended, avoiding any sudden pressure or punching movements. 
During the course of the examination the examiner should first 
palpate a region which is supposed to be normal before proceed- 
ing to the suspected site of disease, as by so doing he gains the con- 
fidence and cooperation of the patient. 

The abdomen should be palpated systematically, the examiner 
examining the state of the abdominal wall, palpating any local 
bulging or retraction Avhich was noted during inspection, and en- 
deavoring to determine whether it is located in the abdominal 
wall or arises within the abdominal cavity, and the state of the 
various solid organs of the abdomen, the technic of palpation of 
which are discussed in their appropriate sections. 

The Abdominal Wall. — An estimate of the thickness of the ab- 
dominal wall may be made by pinching up the wall between 

511 



512 



PHYSICAL DIAGNOSIS 






\ I X, 



w- 






Fig. 203. — Palpation of the abdomen. 
First step. Hand flat on abdominal surface. 
(From Crossen.) 



Fig. 204. — Palpation. Depressing the 
wall with the fingers of one hand, in various 
situations. (From Crossen.) 




Fig. 205. — Palpation with both hands. 
(From Crossen.) 



Fig. 206. — Deep palpation with both hands, 
(From Crossen.) 



PALPATION OF ABDOMEN 



513 



the forefinger and tlmmb, or by approximating the two hands 
placed pahn dowmvard upon the abdominal surface. Increased 
thickness of the abdominal wall indicates an excess of fat, 
the presence of edema, or suppuration of the wall. If the in- 
crease be due to excessive deposition of fat in the wall, a fat wave 
will be obtained upon bimanual palpation; if due to edema, the 
wall will pit upon pressure ; and if due to a localized or extensive 
suppuration of the Avail, there will be accompanying signs of in- 
flammation, as discoloration of the surface, and elevated tem- 
perature. 

Eigidity of the abdominal wall with possibly spasm upon at- 
tempts at palpation, indicates inflammation of the peritoneum or 
of an abdominal organ. Muscular rigidity is most commonly en- 




Fig. 207. — Testing the thickness of the 
abdominal wall. (From Crossen.) 



Fig. 208. — Testing the thickness of the 

abdominal wall. — Second step. The fingers 
carried beneath the wall. (From Crossen.) 



countered in the rectus muscle. Rigidity of the right rectus alone 
occurs with acute appendicitis, whereas bilateral rigidity of the 
recti accompanies acute peritonitis. 

Tenderness. — AYhen tenderness is elicited upon palpation of the 
surface of the abdomen, if not due to hyperesthesia of the pari- 
etes, it points to a diseased abdominal organ. The tenderness is 
most apt to be encountered over the gall bladder, stomach, spleen, 
kidney, appendix, and sigmoid flexure. In acute peritonitis there 
is general or diffuse tenderness. 

Fluid Wave. — In the presence of ascites a fluid wave can be 
demonstrated upon bimanual palpation. In palpating for fluid 
in the peritoneal cavity, one hand of the examiner is applied flatly 



514 



PHYSICAL DIAGNOSIS 



over one lumbar region, while the opposite* side of the abdomen 
is tapped with the other hand of the examiner, the finger-tips 
being used. An impulse or wave is thus created in the fluid, 
which is appreciable to the palpating hand. 

Fat Wave. — Excessive deposition of fat in the abdominal wall 



-^^f^ 





T'O, 



Ut 



T-O. 



Fig. 209. — Various areas of significant point-tenderness. These are the areas to be 
investigated during the course of an abdominal examination. (From Crossen.) 



gives a wave upon bimanual palpation closely simulating the fluid 
wave. To exclude such a fat wave during bimanual palpation an 
assistant should apply the ulnar side of the hand to the median 
line of the abdomen while the examiner practices bimanual pal- 
pation as in eliciting the fluid wave, when the fat wave is inter- 



PALPATION OF ABDOMEN 



515 



rupted by the intervention of the assistant 's hand and is not trans- 
mitted to the palpating hand of the examiner. 

Intraabdominal Tumor. — An intraabdominal tumor may be so 
large as to entirely fill the abdominal cavity ; but as a rule careful 
bimanual palpation enables the examiner to determine its origin, 




Fig. 210. — Trying for a fluid wave across the abdomen. (From Crossen.) 




Fig. 211. — Differentiating a fat wave from a fluid wave. The fat wave is stopped by 
the pressure in the median line. (From Crossen.) 



516 PHYSICAL DIAGNOSIS 

■ * 

its size and shape, whether it is fixed or movable, and finally 
whether it moves with respiration. In examining for respiratory 
mobility of an intraabdominal tumor the examiner should place 
both hands palms downward flat upon the abdomen, with the 
fingers directed toward the costal arch, while the patient is di- 
rected to breathe deeply. At the commencement of expiration, the 
finger-tips are pressed downward firmly and with uniform pres- 
sure, when the lower margin of the tumor or enlarged organ is 
encountered. The most commonly encountered movable ab- 
dominal tumor is a movable or displaced kidney; but tumors 
of the liver and spleen are movable with respiration. 

Peritoneal Friction Fremitus. — Upon palpating over the upper 
regions of the abdomen a friction fremitus analagous to pleural 
or pericardial friction fremitus is sometimes encountered. The 
vibration is produced by roughening of the peritoneal surfaces in 
peritonitis. This fremitus is most commonly encountered over 
the hypochondriac regions, in the presence of peritoneal involve- 
ment in the course of perihepatitis or perisplenitis. 

PERCUSSION 

In the examination of the abdomen the examiner may employ 
instrumental percussion with the hard rubber pleximeter and the 
percussion hammer; he may employ ordinary mediate finger per- 
cussion; he may resort to flicking percussion; or he may employ 
auscultatory percussion. In the determination of minor grades 
of impairment of intestinal or gastric tympany flicking percus- 
sion is very serviceable, while in outlining the various solid vis- 
cera and tumors of the abdominal organs auscultatory percussion 
is a very serviceable and dependable method of procedure. 

In the practice of flicking percussion, the middle finger of the 
left hand should be applied upon the abdominal surface with the 
nail downward, while the middle finger of the right hand is so flexed 
that the nail of the finger is pressed firmly against the palmar 
aspect of the thumb. The percussion stroke is delivered by per- 
mitting the right middle finger to escape in such manner as to 
strike firmly and quickly against the palmar aspect of the finger 
applied to the abdominal surface. 

In general, the percussion note is tympanitic upon percussion 
of the hollow intraabdominal viscera when these contain a moder- 
ate quantity of gas unmixed with any excess of solid material, 
changing to a flat note over the solid intraabdominal organs. A 



PERCUSSION AND AUSCULTATION 



517 



similar flat note is elicited over solid intraabdominal tumors and 
over collections of fluid, whether encysted or free in the peri- 
toneal cavity. 

During percussion of the abdomen the patient should assume 
the dorsal decubitus with the abdominal wall freely exposed to 
the pubes. In delimiting the borders of solid organs and tumors, 
and in the estimation of the relative tympanicity of the adjacent 
hollow viscera auscultatory percussion, with the employment of 
a superficial percussion blow or a light stroking movement upon 
the abdominal surface, is most serviceable. The technic of aus- 
cultatory percussion as applied to the examination of the ab- 
domen differs in no wise from the technic which has been de- 
scribed in a previous section. 





Fig. 212. — Ordinary percussion, which 
is usually rather superficial. (From Cros- 
sen.) 



Fig. 213. — Deep percussion. Notice how 
the left index finger is pressed into the ab- 
domen, so as to thin out the wall and get 
closer to deep structures. (From Crossen.) 



The details of technic of outlining the various abdominal 
viscera are discussed in their appropriate sections. 



AUSCULTATION 

Auscultation is seldom employed in the examination of the 
abdomen and its viscera. Upon auscultation of the abdominal 
surface overljdng the liver or spleen, a friction sound may occa- 
sionally be audible in the presence of perihepatitis or of peri- 
splenitis. Similarly, vascular murmurs have occasionally been 
encountered upon auscultation of the abdomen overlying these 



518 



PHYSICAL DIAGNOSIS 



organs, as a result of transient constrictron of their extensive 
vascular channels. In cases of aortic aneurysm a vascular mur- 
mur may be detected by auscultation over the course of the 
vessel. In cases of suspected pregnancy, again, auscultation is 
available in the search for the fetal heart sound as well as for the 
umbilical or uterine souffle. 



MENSURATION 

Mensuration of the abdomen is practiced in order to determine 
variations in the contour and extent of the abdominal walls in 
the presence of intraabdominal tumors, tympanites, ptosis, or 
cysts. Successive mensuration is practiced to determine any 
progressive enlargement of the abdomen from these conditions 
as well as to arrive at conclusions as to any diminution in these 
dimensions. 




Fig. 214. — Showing the lines for mensuration. (From Crossen.) 



PERCUSSION AND AUSCULTATION 519 

In the practice of mensuration of the abdomen seven lines are 
employed; namely, (1) a line encircling the trunk at the level 
of the umbilicus; (2) a line encircling the trunk three inches above 
the umbilicus; (3) a line encircling the trunk three inches below 
the umbilicus; (4) a line extending from the umbilicus to the 
right anterior superior iliac spine; (5) a line extending from the 
umbilicus to the left anterior superior iliac spine; (6) a vertical 
line extending from the umbilicus to the tii3 of the ensiform 
process; and (7) a vertical line projected from the umbilicus to 
the symphysis pubis. 



SECTION II 



SPECIAL EXAMINATION OF THE ABDOMINAL 

VISCERA 



CHAPTER XXIII 

THE STOMACH, INTESTINES, AND PANCREAS 

EXAMINATION OF THE STOMACH 

Clinical Anatomy. — The stomacli occupies the epigastric and 
left hypochondriac regions of the abdomen when the organ is 
normal. The cardiac orifice of the stomach is located behind the 
seventh left costal cartilage, at a point one inch from the sternum. 
The position of the pyloric orifice is somewhat variable, its site 
being modified by the condition of the stomach. When the stomach 
is empty it occupies the median line at a point midway between 
the episternal notch and the symphysis pubis. When the stomach 
is moderately distended, the pylorus occupies a position approxi- 
mately one inch to the right of the median line at the same level, 
this displacement to the right being increased to two or three inches 
in the presence of extreme distention of the organ. 

The fundus of the stomach is in contact with the inferior aspect 
of the diaphragm, behind and below the apex of the heart, in which 
position it extends as high as the sixth rib. The lesser curvature^ 
representing the superior limit of the stomach, is covered by the 
left lobe of the liver, passing downward and toward the right from 
the cardiac orifice to the pyloric orifice of the stomach. The greater 
curvature, representing the inferior limit of the organ, crosses 
the left costal arch at the level of the ninth costal cartilage, the 
most dependent portion of the normal organ occupying a level ap- 
proximately two inches above the umbilicus. 

The anterior surface of the stomach, largely overlapped by the 
left lobe of the liver, lower border of the left lung, and left costal 
arch, is exposed to the anterior abdominal wall in a very limited 
portion of its extent. Trauhe's semilunar space, the area in which 
the anterior wall of the stomach is in direct contact with the ante- 

520 



EXAMINATION OF THE STOMACH 



521 



rior abdominal wall, affording upon percussion pure gastric tym- 
pany, is limited superiorly by the left lobe of the liver and the 
inferior border of the left lung, and externally by the spleen. 

The posterior surface of the stomach looks backward and down- 
ward, reposing in the so-called ''stomach bed" formed of the 
transverse mesocolon, the pancreas, left kidney, and suprarenal 
capsule. 



^ 



1 



^ 



Fig. 215. — The central upper abdomen. Showing in outline the liver and stomach and 
pancreas. (From Crossen.) 

Physical Examination. — Inspection. — In practicing inspection of 
the abdomen for the detection of affections of the stomach, the 
patient should in the first place assume the dorsal decubitus, with 
a free exposure of the abdomen, the thorax, and the lower cervical 
region. With the subject in the recumbent posture, the examiner 



522 PHYSICAL DIAGNOSIS 

should assume a position with his eyes upbn the level of the ab- 
dominal surface, and should inspect this surface from the left side, 
from the right side, from the feet of the patient, and from the head 
of the patient, with oblique illumination of the abdominal and 
thoracic surfaces. 

The normal stomach in the subject with abdominal walls of 
normal thickness gives no evidence of its presence upon inspection 
of the epigastric and left hypochondriac regions. But, in the pres- 
ence of diastasis of the rectus muscles, and in the emaciated subject 
who has lost much of the paniculus adiposus of the abdominal wall, 
if the stomach is at all distended with gas, it is possible to observe 
a protrusion of the epigastric region, to which is not infrequently 
added a bulging of the left costal arch. In the presence of diasta- 
sis of the recti, visible peristalsis is frequently noted, the peri- 
staltic waves being recognized as a vermicular movement upon the 
abdominal wall which travels from the left side of the epigastrium 
toward the right and downward. Bamberger has described visible 
peristalsis in connection with pyloric stenosis in w^hich, following 
a visible constriction of the central portion of the stomach, the 
peristaltic waves were observed to pass in opposite directions to- 
ward the cardia and toward the pylorus. 

When epigastric bulging of gastric origin is observed upon in- 
spection of the epigastrium, the first point to be settled is the site 
of the greater curvature of the organ, representing the inferior 
limit of the stomach ; and the second detail is to determine whether 
the lesser curvature has departed from its normal site. In the 
presence of gastric dilatation and gastroptosis the greater curva- 
ture is frequently encountered below the level of the umbilicus, and 
it may be as low as the pubes. Its lower limit when the organ is 
distended with gas is indicated by a transverse elevation with its 
convexity directed downward. It is to be borne in mind, however, 
that epigastric bulging is usually due to gaseous distention of the 
stomach, and that pronounced gastrectasis may exist without this 
bulging, provided that the stomach is not filled with gas. In fact, 
in true gastrectasis epigastric bulging is frequently absent, and the 
abdominal wall is frequently scaphoid and flaccid. Hence, gas- 
trectasis and gastroptosis are by no means excluded by the absence 
of epigastric bulging, and further exploratory methods must be 
employed to determine their presence or absence in any case. 

In suspected cases of gastrectasis or gastroptosis, after the pa- 
tient has been examined in the recumbent posture, a further in- 
spection of the abdomen should be conducted with the subject in 



EXAMINATION OF THE STOMACH 523 

the standing' posture with a view to the detection of the more or less 
characteristic changes in the contour of the abdomen in these affec- 
tions. 

The determination of the level of the lesser curvature of the 
stomach is extremely important in dealing with suspected cases of 
gastrectasis and gastroptosis; but, as this curvature is covered by 
the left lobe of the liver, it is inaccessible to inspection in the nor- 
mal subject; and even in the presence of gastroptosis, it is ordina- 
rily necessary to resort to artificial distention of the stomach to 
render it accessible to inspection. 

The artificial distention of the stomach after the method of 
Frerichs is very serviceable in this connection. The subject is 
given a dram of sodium bicarbonate in solution, which is shortly 
followed by a dram of tartaric acid in solution. The reaction 
of the two solutions generates carbon dioxide in the stomach, which 
serves to distend the organ. Frequently this artificial distention 
of the stomach is attended by mild symptoms, such as transient 
dyspnea, anxiety, and acceleration of the pulse, as a result of in- 
creased subphrenic pressure exerting pressure upon the heart. 
These symptoms are, as a rule, transient, and are entirely relieved 
by a few eructations of gas. If they persist and are distressing to 
the patient, they are immediately relieved upon the passage of a 
stomach tube, with evacuation of the gas. 

Artificial distention of the stomach has been practiced by forcing 
air into the viscus through a stomach tube by means of a rubber 
bulb. In this procedure it not infrequently happens that there is 
produced a simultaneous distention of the entire intestinal tract, 
with very little distention of the stomach. The pyloric orifice 
does not seem to react to the inflation of atmospheric air and to 
close as it does in the presence of carbon dioxide. Moreover, the 
inflation with atmospheric air necessitates the employment of the 
stomach tube, which is annoying to the subject of the examination. 

In the presence of gastroptosis and gastrectasis in a patient with 
abdominal walls which are not loaded with fat, upon artificial 
distention of the stomach the two curvatures of the viscus may be 
detected upon inspection, as the stomach assumes a more intimate 
contact with the abdominal wall. In the presence of gastrectasis 
it is further observed that the lesser curvature retains its normal 
position, while the greater curvature extends abnormally low in the 
abdominal cavity, occasionally below the umbilicus or even to the 
pubes. 

In certain cases of pyloric tumor inflation of the stomach causes 



524 PHYSICAL DIAGNOSIS 

a knotty protuberance to become visible in the* region of the pylorus. 
Most frequently these tumors are located to the right and a little 
above the level of the umbilicus. It is noted in the case of gastric 
tumors that they do not move with the respirations, a fact which 
serves to distinguish them from tumors of the liver or of the spleen, 
which possess respiratory mobility. It is possible, however, for a 
gastric tumor to exhibit respiratory mobility if adhesions have 
become established between the new growth and the liver, in which 
event the movements of the liver are communicated to the gastric 
tumor. Occasionally a gastric tumor presents a systolic elevation 
as a result of an impulse which is communicated to the tumor from 
the subjacent abdominal aorta. In this event, upon placing the 
patient in the genupectoral position the tumor falls away from the 
aorta and the systolic elevation is obviated. 

E inborn, Kuttner, Jacobson, and others have introduced various 
types of illuminating apparatus into the cavity of the stomach 
with the view of studying the gastric outlines by the medium of 
transmitted light, a method of examination which was designated 
by Einhorn, gastrodiaphany. Up to the present time gastrodi- 
aphany has not been demonstrated to possess greater clinical value 
than the simpler methods of exploration, as transillumination of 
adjacent viscera is quite possible during the procedure, with conse- 
quent erroneous conclusions. 

Palpation. — In practicing palpation of the stomach, the patient 
should assume the dorsal decubitus with the head comfortably 
elevated by a pillow and the legs drawn up and properly supported, 
in order to relieve the muscles of the abdominal wall from undue 
tension. The examiner, seated upon the left side of the patient, 
should apply the palms of the hands flat upon the epigastrium im- 
mediately below the tip of the ensiform cartilage and gradually 
sink them into the abdominal wall, covering this area progressively 
in a direction from above downward. Following this maneuver, he 
should apply the tips of the fingers of the right hand to the lower 
portion of the epigastrium; and, with the fingers well separated, 
search for the greater curvature of the stomach by a series of gentle, 
pushing movements. 

Palpation of the epigastrium may reveal the presence of tender- 
ness, may confirm visible peristalsis, or the presence of a tumor 
of the stomach, or may elicit succussion sounds. 

Tenderness elicited in the epigastric region, in which such a large 
number of vital structures lie within a limited space, naturally 
possesses a varied significance. It may be significant of simple 



EXAMINATION OF THE STOMACH 525 

inflammation of the mucous lining of the stomach, of ulcer or car- 
cinoma of the stomach, of pancreatic carcinoma or carcinoma of 
the common bile duct, or of acute hepatitis, hepatic colic, pan- 
creatic calculus, or acute pancreatitis. 

In the case of gastric ulcer the tenderness is circumscribed in 
the majority of cases to a point corresponding to the junction of 
a vertical line drawn from the umbilicus to the tip of the ensiform 
cartilage, and of a horizontal line connecting the free margins of 
the eighth costal cartilages. Moreover, gastric ulcer is commonly 
attended by a painful pressure point situated immediately to the 
left of the body of the twelfth dorsal vertebra. 




Fig. 216. — Palpation of the epigastrium. 

The tenderness of acute gastritis and of gastric carcinoma are 
diffuse, pervading all portions of the epigastrium upon deep pres- 
sure. Occasionally, also, in the case of gastric carcinoma it is 
possible, in patients with thin abdominal walls or with diastasis 
of the recti, to palpate the carcinomatous nodules upon the ante- 
rior gastric wall. 

A solid tumor of the stomach may occupy the anterior wall, the 
posterior wall, or the pylorus. A pyloric tumor is commonly pal- 
pable in a circumscribed area to the right of the umbilicus and a 
little above this level. Moreover, pyloric tumors are commonly at- 
tended by varying grades of pyloric stenosis with visible peristalsis 



526 PHYSICAL DIAGNOSIS 

" * 

and an abnormally low position of the greater curvature of the 
stomach. The stomach in this state commonly yields distinct suc- 
cussion sounds even several hours after the ingestion of food or 
fluid. 

A solid tumor of the anterior gastric wall is readily palpable 
by ordinary methods ; but in the uninflated stomach it is impossible 
to say whether a palpable tumor is situated upon the anterior or the 
posterior wall of the viscus. In the determination of the site of 
the tumor under these circumstances artificial inflation of the 
stomach with carbon dioxide is very serviceable. When so dis- 
tended, the tumor situated upon the posterior wall is no longer 
freely palpable. 

The soft, yielding walls of the normal stomach are not palpable 
except in the cases in which the organ has been artificially inflated. 
In the artificially inflated stomach the examiner feels upon palpa- 
tion of the epigastrium a sensation of resistance when the stomach 
is reached, a sensation closely akin to that which is experienced 
upon palpating a rubber bag filled with gas. In the presence of 
gastrectasis and gastroptosis the greater curvature of the organ 
is encountered at an abnormally low level; and in the case of 
gastroptosis it is frequently possible in the inflated organ by 
palpation to outline the lesser curvature of the organ and to es- 
tablish the fact that the superior limit of the stomach has departed 
from its normal habitat beneath the left lobe of the liver. 

Succussion sounds arising within the stomach are elicited by 
palpating the epigastrium with a series of short pushing move- 
ments with the finger-tips, beginning well below the normal site of 
the greater curvature and proceeding upward until this point is 
reached whereupon the splashing sounds will become audible. It 
is not sufficient, however, to cease the palpation when the sounds 
become audible, unless at the same time the fluid becomes palpable. 

Gastric splashing sounds were first described by Chomel, who 
regarded them as an invaluable sign of gastrectasis ; and so they are 
if they fulfill certain topographical and chronological conditions. 
These conditions have been established by Bouchard ; namely, that 
splashing sounds are indicative of gastrectasis when they extend 
well beyond the limits occupied by the normal organ; and when 
they are elicited at least six hours after the ingestion of food or 
fluid. 

GlenarcVs Belt Sign.— In the presence of gastroptosis, when 
the examiner, standing behind the patient, places his hands upon 
the lower portion of the abdomen and lifts upward and backward, 



EXAMINATION OF THE STOMACH 



527 



the patient with gastroptosis experiences a sensation of relief from 
the dragging sensation which accompanies this disease. 

Percussion. — Percussion of the stomach is employed to determine 
the size, shape, and position of the viscns. During the examination 
as in the case of palpation and inspection of the epigastrium, the 
subject should occupy the dorsal decubitus. In the examination of 
the organ by percussion, finger percussion, percussion with the 
hammer, or flicking percussion may be employed with uniformlj^ 
g'ood results in the course of the examination. 





Fig. 217-yi.— Traube's se 



muunar space. 



Fig. 217--B. — Traube's semilunar space. 



The findings upon percussion of the stomach vary with the state 
of the organ. The sound which is elicited depends upon the con- 
tents of the stomach and upon the tension of its walls. According 
to the different variations in these factors the gastric cavity is 
capable of generating pure tympany, a metallic sound, or frank 
flatness. As the stomach is continually presenting active contrac- 
tions and relaxations, the percussion sound which is elicited natu- 
rally changes with great frequency during a brief period of time. 

Pure gastric tympany is only obtained in Traube's semilunar 
space, when the stomach is moderately distended and its walls are 



528 



PHYSICAL DIAGNOSIS 



not under undue tension. This area, corresponding to the portion 
of the anterior gastric wall which is in direct apposition with the 
thoracic and abdominal surface, presents a transverse diameter of 
four to five inches and a vertical diameter of three to four inches. 
The space possesses three distinct limits which may be determined 
by alterations in the quality and pitch of the percussion sound. 
Superiorly and to the left the gastric tympany is interrupted by 
the inferior border of the left lung, the gastropulmonary limit of 
the space ; superiorly and toward the right it is interrupted by the 




Fig. 218. — Illustrating point of epigastric tenderness in gastric ulcer. 

left lobe of the liver, the gastrohepatic limit; while inferiorly it is 
interrupted by the colonic tympany of the transverse colon, con- 
stituting in this situation the gastrocolic limit of gastric tympany. 
In the minimal number of cases in which the tip of the left lobe 
of the liver does not reach the apex of the heart, there exists yet 
another change in the percussion sound in this situation, constitut- 
ing a gastrocardiac limit of Traube's space. 

The gastropulmonary and gastrohepatic boundaries of the semi- 
lunar space of Traube are readily determined by mediate percus- 
sion with the fingers from an area of frank gastric tympany in the 



EXAMINATION OF THE STOMACH 



529 



central portion of this area toward the lung and the liver respec- 
tively. The delineation of the gastrocolic boundary of the space is 
more difficult, owing to the fact that it is possible for the gastric 
and the colonic tympany to approximate one another in quality and 
pitch. This difficulty is obviated by the introduction of a liter 
of fluid into the stomach prior to the examination. Upon per- 
cussing upward under these conditions, the colonic tympany gives 
place to dullness or flatness, when the greater curvature of the 
stomach is reached. 

Auscultatory percussion is to be preferred, however, in the 
accurate determination of the size, shape, and position of the 
stomach. In this method of examination the chestpiece of the 




Fig. 219. — Ilhistrating dorsal pressure point in gastric ulcer. 



stethoscope is applied at the center of gastric tympany in Traube's 
space. The examiner delivers a few blows and fixes in his mind the 
quality and pitch of the sound elicited. Without moving the posi- 
tion of the bell of the instrument, he then begins at several points 
upon the abdominal surface and percusses toward the bell of the 
stethoscope. In each instance a change in the quality of the per- 
cussion note will indicate when the gastric border has been reached. 
Scratching percussion is also very serviceable in delimiting the 
borders of the stomach. In this procedure the examiner applies 
the bell of the stethoscope to the area of frank gastric tympany 



530 



PHYSICAL DIAGNOSIS 



in Traube's semilunar space and scratches the skin of the abdomen 
in this area with the nail. Having fixed in his mind the quality 
and pitch of the sound elicited, he begins at various regions of the 
abdominal surface and passes the finger-nail along the skin toward 
the bell of the instrument. A change in the quality of the sound is 
noted in each instance when the gastric borders are reached. The 
rubber tip of the percussion hammer is very serviceable in scratch- 
ing percussion, as is also the eraser upon the end of a lead pencil, 
whieli is drawn across the skin toward the bell of the instrument. 
In each instance the quality of the sound changes abruptly when the 
gastric borders are attained. 



Fig. 220. — Showing the region for tenderness or a mass from disease of the stomach or 
pancreas. (Froin Crossen.) 



An extension of the area of gastric tympany does not in every 
case in which it is encountered indicate an increase in the volume 
of the organ. In the presence of atrophic changes in the liver the 
left lobe of this organ is retracted toward the median line and 
the gastric tympany is extended in this direction, with the conse- 
quent production of a gastrocardiac limit of the space of Traube. 
Similarly, in the presence of retraction of the anterior and inferior 
borders of the left lung in the course of chronic interstitial pneu- 
monia, fibroid phthisis, or pulmonary syphilis, the gastric tympany 
is extended in a direction upward and outward as a result of re- 
traction of the gastropulmonary limit of this space. 

Extension of the area of gastric tympany as a result of enlarge- 



\ 



EXAMINATION OF THE STOMACH 531 

ment of the organ itself is encountered in the presence of gastrecta- 
sis and in congenital enlargement of the organ, (megalogastria). 
In gastroptosis, on the contrary, although the inferior limit of the 
area of gastric tympany is markedly lowered, it can be determined 
by careful percussion that the lesser curvature no longer resides 
in its normal habitat beneath the left lobe of the liver. Again, in 
the case of gastrectasis, an error is apt to arise through the accu- 
mulation of fluid in the dilated stomach if care is not exercised to 
evacuate this fluid prior to the examination. 

Diminution of the extent of gastric tympany is by no means in- 
variably associated with diminution in the size of the stomach. In 
hepatic enlargements the left lobe of the liver encroaches upon the 
semilunar space of Traube and causes downward displacement of 
the gastrohepatic limit of this space. Similarly, in the presence of 
left-sided pleural effusions and pyopneumothorax, the gastropul- 
monary limit of the space is lowered with consequent diminution in 
the limits of gastric tympany. Pitres has noted diminution in 
the dimensions of gastric tympany in connection with extensive 
effusion into the right pleural sac, which he attributes to crowding 
over of the liver by the weight of the effusion. The presence of 
varying quantities of solids and fluids in the stomach diminishes 
the area of gastric tympany. 

Diminution of the area of gastric tympany which is referable 
directly to diminution in the size of the stomach is occasionally 
demonstrable in the presence of cardiac stenosis from malignant 
disease of the cardiac orifice of the stomach. However, in this 
event the atrophic stomach as a rule is pushed upward and back- 
ward by the transverse colon and in no wise enters into the tympany 
which is produced upon percussion in Traube 's semilunar space. 
Indeed, Dehio has demonstrated, both upon the living subject and 
upon the cadaver, that when the normal stomach is empty the tym- 
pany which is obtained upon percussion of Traube 's space is inva- 
riably due to the transverse colon, which crowds the empty stomach 
upward into the left concavity of the diaphragm. 

An hour-glass constriction of the stomach may be demonstrated 
by the introduction of water into the stomach ; when, upon percus- 
sion over the viscus, it is observed that the stomach is not uniformly 
distended ; but that the cardiac portion is distended, while the 
pyloric portion remains empty ; and, moreover, that in a short time 
fluid passes into the pyloric portion, which in turn becomes dis- 
tended. If, during this time, the stethoscope be applied over the 



532 PHYSICAL DIAGNOSIS 

■ * 

central portion of the stomach, it may be possible to hear the water 
gurgle through the constricted portion of the organ. 

Auscultation. — Succussion sounds which are generated in the 
stomach and which are audible during palpation possess a corre- 
spondingly greater intensity upon auscultation of the epigastrium, 
and are propagated to a considerable distance from their site of 
production. In eliciting these sounds by auscultatory percussion, 
the patient should assume the dorsal decubitus with the abdominal 
muscles relaxed. The bell of the stethoscope is placed over the 
central portion of Traube's space and the epigastrium is gently 
tapped with the finger-tips of the opposite hand of the examiner, 
whereupon the examining ear appreciates a series of sounds analo- 
gous to those which are produced upon shaking a rubber bag which 
is partially filled with fluid. Demonstrable in the normal stomach 
when it contains coincidentally air and fluid, the succussion sound 
possesses a much greater range of intensity and area of propaga- 
tion in the case of gastrectasis. 

Upon auscultation of the stomach in the presence of gastrectasis 
with active fermentation of the gastric contents, the examiner fre- 
quently encounters a series of fine crackling sounds, caused by the 
bursting of minute bubbles upon the surface of the contained fluid, 
the enlarged stomach amplifying and acting as a resonator for the 
sounds. These sounds are never audible below the inferior curva- 
ture of the stomach ; and, when they are demonstrable in the pres- 
ence of a dilated stomach, serve as a reliable guide in checking the 
findings upon palpation and percussion of the organ. 

Kronicker and Meltzer first called attention to two deglutition 
sounds which are audible upon auscultation of the superior portion 
of the epigastrium immediately below the tip of the ensiform carti- 
lage. The first of these sounds is simultaneous with the act of 
deglutition, while the second which is attributed to the passage 
of the ingested fluid through the cardiac orifice, is audible approxi- 
mately seven seconds after the first sound. In the presence of 
partial stenosis of the cardiac orifice of the stomach the second 
sound is replaced by an irregular spouting, churning sound as the 
ingested fluid passes through the constricted orifice. In the pres- 
ence of complete stenosis of the cardia, the second deglutition 
sound is abolished. 

EXAMINATION OF THE SMALL INTESTINE 

Clinical Anatomy. — The small intestine, the section of the 
gastrointestinal tract extending from the pyloric orifice of the 



EXAMINATION OF THE SMALL INTESTINE 



533 



stomacli to the junction with the large intestine at the ileocecal 
valve, lies within the frame formed by the course of the large 
intestine, slightly overlapping the ascending and the descending 
colon, and extending for a variable distance below the brim of 
the pelvis. 

The duodenum, the proximal twelve inches of the small intestine, 
pursues a course resembling the letter ' ' C " from the pylorus to the 



> 



?:•■ 




;j 



Fig. 221. — The left upper abdomen. The site of the spleen and of the splenic flexure 
of the colon, the organs in this region most commonly affected, are shown by the stip- 
pling. When normal, the spleen lies considerably higher in the abdominal cavity than is 
generally supposed. Its anterior projection is shown here in dotted outline, with the 
lower end in contact with the splenic flexure of the colon. (From Crossen.) 



duodenojejunal flexure at the left side of the second lumbar verte- 
bra, embracing in its course the head of the pancreas and the com- 
mon bile duct, which empties its contents into this portion of the 
small intestine. 



534 PHYSICAL DIAGNOSIS 

The jejimum, the second division of the* small intestine, com- 
prising approximately eight feet of the tnbe, lies in the umbilical 
and right and left lumbar regions, and is freely movable. 

The ileum, the distal twelve feet of the small intestine, which 
terminates at the ileocecal valve, lies in the umbilical, hypogastric, 
and lumbar regions, in which it is freely movable. Only the great 
omentum intervenes between the jejunum and ileum and the ante- 
rior abdominal wall. 

Physical Examination. — Inspection. — In the normal subject 
with well-developed abdominal walls inspection of the abdomen 
yields no evidence of the presence or location of the coils of the 
small intestine. In the emaciated subject, however, and in subjects 
presenting diastasis of the rectus muscles, visible perastalsis is 
occasionally detected in the absence of intestinal pathology ; and in 
the presence of intestinal obstruction this ]3eristalsis is greatly 
exaggerated. If the site of the obstruction is in the lower portion 
of the ilium, near the ileocecal valve, the peculiar "ladder pat- 
tern" is frequently noted, occupying the umbilical region. 

Palpation. — The soft yielding walls of the normal small intestine 
are not to be felt upon palpation of the abdominal wall. But in 
the subject with thin abdominal walls enteroliths or large gall- 
stones may occasionally be detected by palpation if they are pres- 
ent. A hard tumor which is encountered in the neighborhood of 
the umbilicus and in the lower umbilical and upper hypogastric 
regions is very apt to belong to the small intestine, and may be 
significant of malignant disease, of intussusception, or of volvulus. 
A solid mass encountered in these regions, however, is occasionally 
due to matting of the omentum in tuberculous peritonitis, consti- 
tuting tabes mesenterica. 

When an intestinal tumor pulsates, the patient should be placed 
in the genupectoral position, in order to determine whether the 
pulsation is transmitted to the tumor from the subjacent abdominal 
aorta. When palpation of the intestine is practiced in this posture, 
the tumor falls away from the aorta, and the pulsation of this 
vessel is no longer imparted to the growth. 

Percussion. — The note which is elicited upon percussion of the 
small intestine varies in pitch and quality with the amount of gas 
contained in the tube and with the tension of its walls. The normal 
intestine yields a tympanitic or metallic percussion sound, but in 
the presence of a considerable content of solid material, the note 
becomes dull. When the intestine is greatly distended with gas in 
intestinal obstruction, the note is frankly tympanitic, but of slightly 



EXAMINATION OF THE SMALL INTESTINE 535 

lower pitch than in the case of percussion of the normal intestine 
with only moderate tension of its walls. A similar percussion note 
is encountered in the presence of a solid tumor which is surrounded 
by tympanitic intestine. The same note is encountered in the 
presence of multiple incomplete stenoses of the intestine as the 
result of tuberculous ulceration. Frequently under these circum- 
stances there is accumulation of fluid above the level of each of the 
obstructions, yielding impairment of intestinal tympany in multiple 
areas of the abdominal surface, constituting the sloping dullness 
of Mathieu and Ricard. 

Auscultation. — Upon auscultation of the abdominal wall over 
the distribution of the small intestine, the examiner frequently 
encounters transient gurgling sounds, 'bor'borygmi, which are with- 
out diagnostic significance. But in the presence of a partial ob- 
struction of the intestine, auscultation at the level of the stenosis 
reveals a more intense fluid sound, resembling that which is pro- 
duced by the sudden expulsion of liquid from a syringe. In the 
presence of multiple partial intestinal stenoses due to tuberculous 
ulceration Konig has encountered these fluid sounds at varying 
levels of the abdominal wall, accompanied by succussion sounds 
upon palpatory percussion and by the sloping dullness of Mathieu 
and Ricard. 

EXAMINATION OF THE LARGE INTESTINE 

Clinical Anatomy. — The large intestine, comprising the terminal 
six feet of the gastrointestinal canal, comprises the cecum with 
the vermiform appendix, the ascending, transverse, and descend- 
ing colon, the sigmoid flexure and the rectum. The large intes- 
tine is arranged in the form of a frame enclosing the coils of the 
small intestine upon the right side of the abdomen, superiorly, 
and upon the left side of the abdominal cavity, the ascending colon 
and the descending colon being slightly overlapped by the coils 
of the small intestine. 

The cecum, with the vermiform appendix, occupies the right 
iliac and the hypogastric regions. The cecum, comprising the 
blind extremity of the great intestine, and which lies inferiorly to 
the ileocecal valve, is approximately three inches in diameter and 
two and one-half inches in length. The vermiform appendix is a 
slender appendage of the cecum, usually approximately four 
inches in length and one-fourth inch in diameter, which is com- 
monly given off from the postero-internal surface of the cecum. 



536 PHYSICAL DIAGNOSIS 

The appendix is quite free and mobile, and while it frequently 
inclines downward toward the brim of the true pelvis, it may be 
deflected in other directions. 

The ascending colon ascends vertically in the right lumbar and 
right hypochondriac regions in contact with the anterior wall of 
the abdomen to reach the inferior surface of the liver at the 



1 



\ 
\ 
\ 



Fig. 222. — The right lower abdomen. The organs commonly affected, and the areas ac- 
cordingly of particular interest, are indicated by the stippling. (From Crossen.) 

level of the tenth right costal cartilage. At this level the colon 
is flexed toward the left and downward, forming the hepatic 
flexure, which terminates in the transverse colon. The ascending 
colon is approximately eight inches in length ; and in its ascent it 
is in relation with the anterior surface of the right kidney, and it 
terminates in the hepatic flexure at a point upon the inferior 



EXAMINATION OF THE LARGE INTESTINE 537 

surface of the liver which, is situated external to the gall bladder. 
In a subsequent paragraph it will be shown that the anatomical 
relations of this portion of the large intestine to the right kidney 
and to the gall bladder may be utilized in the differential diagnosis 
of tumors springing from these structures. 

The transverse colon crosses the abdominal cavity, descending 
from the right hypochondriac region into the upper portion of 
the umbilical region; thence ascending obliquely into the left 
hypochondriac region to the inferior extremity of the spleen to 
form the splenic flexure of the colon. The transverse colon, ap- 
proximately twenty inches in length, is attached to the posterior 
abdominal wall by a broad fold of peritoneum, the transverse 
mesocolon, and it is the most freely mobile portion of the large 
intestine. Anteriorly the transverse colon is in apposition with 
the anterior abdominal wall, the great omentum alone interven- 
ing between the two structures. Posteriorly the transverse colon 
is in relation with the second or descending portion of the duo- 
denum, and with coils of the small intestine. The transverse colon 
and transverse mesocolon serve in some sort as a dividing factor 
in the abdominal cavity, the liver, gall bladder, stomach, and 
spleen lying above this portion of the great intestine; and the coils 
of the small intestine occupying a position below its level. 

The descending colon, commencing at the splenic flexure, passes 
vertically downward in the left lumbar and left iliac regions, to 
terminate in the sigmoid flexure in the hypogastric region. The 
descending colon is approximately nine inches in length; it is in 
relation anteriorly and laterally with the abdominal walls; and 
posteriorly it is in relation with the outer border of the left kid- 
ney and with the muscles forming the posterior abdominal wall. 

The sigmoid flexure is approximately thirteen inches in length, 
commencing at the level of the iliac crest and terminating at the 
brim of the true pelvis in the rectum opposite the left sacro-iliac 
joint. The sigmoid flexure is the narrowest portion of the large 
intestine. When empty and collapsed, it falls into the recto- 
vesical or rectovaginal pouch ; but when distended with fecal ac- 
cumulation or with gas it mounts up into the abdominal cavity, 
occasionally reaching the level of the umbilicus. The sigmoid 
flexure is attached to the posterior abdominal wall by a fold of 
peritoneum, the mesosigmoid, which permits this portion of the 
large intestine to enjoy a considerable degree of mobility. As a 
result of this free mobility the sigmoid flexure is occasionally 
the site of volvulus, an accident which is favored in many cases 



538 PHYSICAL DIAGNOSIS 

by elongation of the mesosigmoid from th^ weight of accumula- 
tion of fecal material in chronic constipation. 

The rectum, the terminal portion of the large intestine, is ap- 
proximately nine inches in length. Commencing at the brim of 
the true pelvis at the left sacro-iliac joint, it passes obliquely 
downward and inward to reach the third sacral joint, whence it 
continues its course directly downward in the median line of the 
pelvis to a point one inch below the tip of the coccyx, where it 
turns abruptly backward to form the anal canal. 

Physical Examination. — Inspection. — The undistended large in- 
testine, in the normal subject with abdominal walls in which the 
musculature is not impaired, gives no clue to its presence upon in- 
spection of the abdomen. In the presence of pronounced gaseous 
distention of the colon, however, there is frequently a visible 
tumefaction in the right and left lumbar and in the hypogastric 
regions, which corresponds to the course of the ascending colon, 
the descending colon, and the sigmoid flexure, which in the state 
of gaseous distention mounts upward into the abdominal cavity 
proper. Gaseous distention of the transverse colon produces a 
protrusion in the umbilical region just above the umbilicus. 

A circumscribed protrusion observed over the course of the 
colon, which persists and is demonstrable upon consecutive exam- 
inations, is apt to be due to a solid tumor of the colon. In such 
event it is attended by local tenderness upon palpation as a re- 
sult of coincident peritoneal inflammation. In other instances a 
protrusion along the distribution of the colon is due to fecal im- 
paction, in which event the tumefaction is transient and is re- 
lieved by thorough catharsis. 

Palpation. — In the palpation of a tube of such extensive dis- 
tribution and one which possesses such a variety of anatomical 
relations in different portions of its distribution, it is evident 
that a maneuver which is applicable to one portion of the tube is 
not applicable in other portions. As a result of the changes in 
direction of the colon with reference to the different diameters of 
the abdominal cavity, it is necessary to palpate difl'erent portions 
of the tube in different planes. 

In the practice of palpation of the cecum the examiner, seated 
at the right side of the patient, applies the right hand over the 
end of the gut in the right lumbar and hypogastric regions and 
gradually sinks the fingers of the hand downward with a rolling 
movement, endeavoring in this manner to outline the cecum. The 
gurgling murmur which is frequently set up by this maneuver 



EXAMINATION OF THE LARGE INTESTINE 



539 



possesses no untoward significance. During this examination an 
attempt should be made to palpate the vermiform appendix, 
which is often to be felt along a line extending from McBurney's 
point toward the symphysis pubis as a cord about the size of a 
lead pencil and about the length of the little finger. A very serv- 
iceable method of palpating for the appendix consists in applying 
the finger-tips of both hands to the abdominal wall in the umbil- 
ical region, just to the right and a little below the umbilicus, and 
exerting pressure and at the same time moving the hands down- 
ward and outward over the abdominal wall toward the right an- 
terior superior iliac spine. In this maneuver there is often felt 
under the fingers the small outline of the appendix. 




Fig. 223. — Indicating the point to seek foi 
appendix tenderness. (From Crossen.) 



Fig. 224. — Palpating for tenderness or a 
mass in the appendix region. (From Cros- 
sen.) 



If tenderness is encountered in the region of the cecum and 
appendix, and this is the most valuable finding upon palpation of 
this region, it is necessary to employ more careful palpation. In 
this instance, the tip of the index finger should be sunk slowly 
into the abdominal wall in the attempt to more accurately local- 
ize the area of local tenderness. 

Tenderness elicited over the cecum points to appendicitis, typh- 
litis, perit^^phlitis, paratyphlitis, tumor, or tuberculous ulcer- 
ation of the intestine. In the case of typhlitis, perityphlitis or 
paratyphlitis, in addition to tenderness there is a distinct feeling 
of resistance to the palpating hand, and the tenderness is rather 
diffuse as compared to that of acute appendicitis which is rather 



540 



PHYSICAL DIAGNOSIS 



closely circumscribed to McBurney's point or to a spot slightly 
below this point. In interpreting the significance of local ten- 
derness elicited in this region, it is worth while to remember that 
tuberculous ulceration of the intestinal tract is particularly lia- 
ble to manifest itself in the ileocecal region. In the case of in- 
testinal carcinoma, it is occasionally possible in the sensitive area 
to detect nobby bosses upon the intestinal wall. 

In palpation of the ascending colon the patient should in the 
first instance assume the dorsal decubitus with the knees drawn 
up and supported; and, if examination in this posture is not sat- 
isfactory, the patient should be placed in the left lateral decubitus 
in order to cause the coils of the small intestine to fall away to- 




Fig. 225. — Palpating for the appendix 
itself, to determine whether or not there is 
any appreciable infiltration and thickening 
of it. When thickened, the appendix is felt 
as a small tender roll, deeply placed. 
(From Crossen.) 



Fig. 226. — Another method of palpating 
the appendix. Beginning near the umbili- 
cus, the fingers are carried in deeply and 
then brought slowly outward toward, the 
anterior superior iliac spine. As the ap- 
pendix passes under the examining fingers, 
it is felt as a small roll between the fingers 
and the posterior abdominal wall. (From 
Crossen.) 



ward the left side of the abdominal cavity, leaving the fixed as- 
cending colon free to manual palpation. 

With the patient in the dorsal decubitus the examiner assumes 
a position by the right side of the patient and applies the finger- 
tips to the abdominal wall along the distribution of this portion 
of the intestine at right angles to the course of the ascending 
colon. By sinking the finger-tips into the abdominal wall and 
moving them outward with a sinking, rolling movement, the as- 
cending colon frequently is felt between the finger-tips and the 



J 



EXAMIXATIOX OF THE LARGE IXTESTIXE 541 

posterior abdominal wall, and the examiner may determine 
Avhether it is distended or contracted, whether its wall is free or 
is studded with nodulations, and whether it contains fecal masses. 
In this connection, it is well to remember that fecal accumulations 
are more frequently encountered in the cecum and ascending 
colon than elsewhere. 




^\5 



^ 



Fig. 227. — The left lower abdomen. The organs commonly affected, and the areas ac- 
cordingly of particular interest, are indicated by the stippling. (From Crossen.) 

If the palpation of the ascending colon in the dorsal decubitus 
is not entirely satisfactory, the maneuver should be repeated with 
the patient occupying the left lateral decubitus with the knees 
drawn up in order to relax the tension of the abdominal muscles. 
As the ascending colon is moored to the anterior face of the right 
kidney by areolar tissue, this portion of the intestinal tract is 



542 PHYSICAL DIAGNOSIS 

freely movable with the kidney ; and in the presence of renal en- 
largement the ascending colon is pnshed forward in front of the 
enlarged kidney. 

During palpation of the transverse colon the patient assumes the 
dorsal decubitus while the examiner jDlaces both hands flat upon 
the abdomen in the umbilical region with the finger-tips extend- 
ing somewhat above the level of the surface markings of the 
normal colon as it dips into and ascends from this region of the 
abdomen. The patient is directed to inspire deeply; and at the 
commencement of the following expiration the examiner makes 
downward pressure with the finger-tips and endeavors to deter- 
mine the position and state of this portion of the intestine. In 
palpation of this section of the colon, as in the case of other por- 
tions, the hand should be applied to the abdominal surface at 
right angles to the course of the colon. Hence, if the transverse 
colon pursues an arched course with the convexity directed down- 
ward, as is very frequently the case, the right and left halves of 
this portion of the intestine must be palpated in different direc- 
tions. While the normal transverse colon is encountered at the 
level of or above the umbilicus, in enteroptosis it may be encoun- 
tered as low as the symphysis pubis. 

The descending colon is palpated with the patient in the dorsal 
decubitus or in the right lateral decubitus, the technic of the 
examination corresponding in all its essentials to the method 
employed in palpation of the ascending colon. 

Palpation of the sigmoid flexure is performed with the patient 
in the dorsal decubitus, the examiner, seated at the left side of the 
subject, placing the fingers of the right hand upon the abdomen 
at right angles to the course of the gut, rolling the intestine be- 
tween the finger-tips and the iliac fossa, searching for tender- 
ness, muscular rigidity, tumor, or fecal impaction. As a general 
rule impacted feces will readily pit upon pressure, whereas a solid 
tumor will fail to do so. Moderate tenderness over the sigmoid is 
not infrequently encountered in the course of diarrhea from any 
cause; and in dysentery of specific origin it is as much more pro- 
nounced. 

Percussion. — As in the case of the small intestine, the findings 
upon percussion of the colon are variable and extremely difficult 
of correct and accurate interpretation. The note elicited upon 
percussion of the colon containing gas is frankly tympanitic or 
metallic, its quality and pitch varying with the tension of the 
colonic walls. Yet it is practically impossible at the bedside to 



EXAMINATION OF THE LARGE INTESTINE 543 

differentiate the percussion sounds elicited upon percussion of 
the stomach, the small intestine, and the colon with any degree 
of accuracy, as the quality and pitch of the sounds vary with 
variations in the tension of the walls of the various portions of 
the intestinal tract; and it is possible for coils of the small in- 
testine, in spite of their lesser size and capacity to yield a tympan- 
itic note quite analogous to that which is generated in the moder- 
ately distended colon when the coils of the small intestine are 
strongly distended with gas and their walls rendered very tense. 
The tympany of the transverse colon is differentiated from that 




Fig. 228. — Palpation of ascending colon. 

of the stomach with most ease when the latter organ is partiall}^ 
filled with fluid. The presence of fecal accumulations in the vari- 
ous portions of the large intestine masks the tympanitic quality 
of the percussion note, yielding varying degrees of dullness upon 
percussion. 

Auscultation. — The chief value of auscultation in connection 
with the examination of the large intestine is in auscultatory per- 
cussion in differentiating the gastric and the colonic tympany. 
Auscultation frequently reveals the presence of gurgling sounds 
over the cecum in the presence of typhoid fever, which are in no 
wise pathognomonic of this disease. Similarly, in the presence 



544 PHYSICAL DIAGNOSIS 

of severe diarrhea or dysentery gurgling is encountered over tlio 
sigmoid flexure. 

Very rarely is the examiner able to detect upon auscultation a 
peritoneal friction sound in the presence of inflammation of the 
walls of the colon or in the presence of miliary tuberculosis or 
malignant disease of this tract. 

The physical examination of the gastrointestinal tract should 
in all cases be abetted by the chemical and microscopical exam- 
ination of the gastric contents and the feces, by illumination of 
the rectum; and when pathologic lesions of the tract are sus- 
pected, fluoroscopy should be practiced by a skilled roentgen- 
ologist. 




Fig. 229. — Palpation of the descending colon. 

EXAMINATION OF THE PANCREAS 

Clinical Anatomy. — The pancreas is an elongated, solid organ, 
comprising a head, neck, body, and tail, situated deeply in the epi- 
gastric region, its tail, however, extending into the left hypochron- 
driac region. 

The pancreas in the adult subject is approximately six inches 
in length, and its location in the abdominal cavity corresponds to 
the level of the first and second lumbar vertebrae. The head of 
the pancreas is encircled by the second and third portions of the 
duodenum, the common bile duct intervening between the two 



EXAMINATION OF THE PANCREAS 



545 



structures, while the tail extends toward the left and is in relation 
with the hilum of the spleen. 

The body of the pancreas is roughly prismatic in shape and 
possesses three surfaces, which respectively are directed ante- 




Fig. 230. — Relations of pancreas to adjacent viscera. 
7, aorta; 2, inferior vena cava; ?, esophagus; 4, splenic artery; 5 and 6, ureters; KK, 
right kidney; LK, left kidney; D, duodenum; P, pancreas; S, spleen. (From Eisendrath.) 

riorly, posteriorly, and inferiorly. The anterior surface, covered 
by the peritoneum of the lesser sac, is in relation with the poste- 
rior wall of the stomach, the transverse colon, and a few coils of 



546 PHYSICAL DIAGNOSIS 

the small intestine. The posterior surface* devoid of peritoneal 
covering, rests upon the abdominal aorta, the inferior vena cava, 
the right crus of the diaphragm, the splenic vein, the left kidney, 
renal vessels, and suprarenal capsule, and the commencement of 
the superior mesenteric artery. The posterior aspect of the neck 
of the pancreas is in relation with the commencement of the portal 
vein. The inferior surface is in relation with the duodenojejunal 
flexure of the small intestine, a few coils of the jejunum, and its 
left extremity rests upon the splenic flexure of the colon. As a 
result of the intimate relation of the pancreas to so many impor- 
tant blood vessels, enlargements of the gland are not infrequently 
attended by vascular bruits due to narrowing of the lumen of one 
or more of these vascular trunks. Similarly, in malignant dis- 
ease of the head of the pancreas, the common bile duct, interven- 
ing between this portion of the gland and the second portion of 
the duodenum is frequently compressed with the production of 
icterus, which may simulate that of hepatic disease. 

The pancreatic secretion is conveyed to the second portion of 
the duodenum by the pancreatic duct of Wirsung, which empties 
its contents into this portion of the intestine by a common orifice 
with the common bile duct. Occasionally the pancreas possesses 
an accessory excretory duct, the duct of Santorini, which empties 
its contents into the second portion of the duodenum approxi- 
mately one inch above the level of the orifice of the principal pan- 
creatic duct. Stenosis of the pancreatic duct usually leads to cys- 
tic enlargement of the pancreas; and the entrance of infective 
bacteria from the intestine by way of the pancreatic duct may 
induce suppurative disease of the pancreas. Malignant disease 
of the pancreas usually involves the head of the gland to the ex- 
clusion of other portions, and carcinoma comes first in frequency 
among pancreatic morbid growths, although sarcoma and ade- 
noma also attack the gland. 

The pancreas crosses the lower portion of the epigastric region, 
the tail of the gland extending approximately two inches into the 
left hypochondriac region, and the lower extremity of the head 
of the gland dipping into the upper portion of the umbilical re- 
gion. The lowest point of the gland occupies a position approxi- 
mately three inches above the umbilicus. 

Physical Examination. — Owing to the profound situation of the 
pancreas in the abdominal cavity and as a result of its rather 
flatly prismatic conformation, physical examination of the organ 



EXAMINATION OF THE PANCREAS 547 

practically resolves itself into the practice of palpation, occasion- 
ally aided and abetted by auscultation. 

The examiner will very rarely be able to palpate the normal 
pancreas, save possibly in the emaciated subject with diastasis of 
the rectus muscles. Leube and Ewald have been able to palpate 
the normal organ when the stomach and intestine were empty; 
but as a rule, the examiner may anticipate considerable difficulty 
in palpation of the normal pancreas. 

When a mass is encountered in the deeper portion of the lower 
epigastric or upper umbilical region, it may be due to a solid 
tumor or a cyst of the pancreas ; and pancreatic solid tumors in 
the vast majority of cases are carcinomatous. 

A tumor arising from the pancreas is apt to be mistaken for a 
tumor of the pylorus, a distended gall bladder, aortic aneurysm, 
or a tumor of the transverse colon. A pyloric tumor is always 
more superficial than is a pancreatic growth'. Moreover, a tumor 
at the pylorus is freely movable, in marked contrast to the immo- 
bility of pancreatic tumors, and pyloric tumors are prone to pro- 
duce pyloric stenosis with consequent gastrectasis. A distended 
gall bladder exhibits lateral mobility; it is more superficial than 
is a tumor of the pancreas; and it is not accompanied by glycosuria 
and fatty stools as are pancreatic growths very frequently. 

A pancreatic tumor may be elevated with each pulsation of the 
abdominal aorta, simulating aortic aneurysm; but while the pulsa- 
tion of aortic aneurysm is expansile and is exercised in all direc- 
tions, that of a superjacent pancreatic tumor is not expansile, the 
mass being simply elevated with each pulsation of the subjacent 
aorta. 

A tumor of the transverse colon is very superficial ; it is freely 
mobile ; it is prone to cause constipation ; and blood is frequently 
demonstrable in the stools with such growths. 

A pancreatic cyst occasionally acquires a considerable size, and 
manifests itself upon palpation as a resistant, fluctuating tumor. 
There is danger of confounding them with hydatid cysts of the 
liver, or with ovarian cysts when these attain huge dimensions. 
In the differential diagnosis of pancreatic and ovarian cysts, 
Kuester has directed attention to the fact that in the case of pan- 
creatic cyst the inferior border of the cyst is always separated 
from the symphysis pubis by a considerable zone of intestinal 
tympany, whereas in the case of a cyst springing from the ovary 
this zone of tympany in the hypogastric region is absent. In the 
differentiation of pancreatic cysts and hydatid cysts of hepatic 



548 PHYSICAL DIAGNOSIS 

■ * 

origin, Kiiester practices artificial distention of the stomach with 
carbon dioxide, whereupon it is readily demonstrated in the case 
of pancreatic cysts that the tumor is situated behind the stomach 
and is in no wise connected with the hepatic region. 

As a result of the intimate relations of the pancreas to a large 
number of important vascular trunks, in the presence of enlarge- 
ment of the gland, auscultation frequently reveals the presence 
of vascular bruits as a consequence of narrowing of the lumen 
of these vessels. 



CHAPTER XXIV 

EXAMINATION OF THE LIVER AND GALL BLADDER 

Clinical Anatomy. — The liver, the largest gland of the body, 
occupies the upper right quadrant of the abdominal cavity, lying 
in the right hypochondriac region, the larger portion of the 
epigastric region, the thin extremity of the left lobe extending 
into the left hypochondriac region, and the inferior extremity of the 
right lobe invading the right lumbar region for a short distance. 
The liver is roughly wedge-shaped, with the wide base directed 
toward the right, and the thin sharp edge of the wedge directed 
toward the left side of the abdomen. The normal adult liver 
measures eight to nine inches transversely, six to seven inches 
vertically at the base of the wedge, and four to five inches antero- 
posteriorly at a point on a level with the upper border of the right 
kidney. 

The liver is divided into two unequal portions, the right and 
left lobes, by the falciform ligament and longitudinal fissure, the 
right lobe greatly exceeding the left lobe in size. At the point 
where the falciform ligament joins the inferior margin of the 
liver there is a small notch, the umbilical notch, which is situated 
at the level of the ninth right costal cartilage one inch to the right 
of the median line. Slightly beyond this notch the liver presents 
a second notch, in which is lodged the fundus of the gall bladder, 
corresponding to the junction of the ninth rib and the right bor- 
der of the rectus muscle. 

The superior surface of the liver, smooth and convex, is closely 
applied to the concave right vault of the diaphragm. Upon its 
central portion the superior surface of the liver presents a shal- 
low depression, the cardiac depression, corresponding to the posi- 
tion of the heart upon the superior surface of the diaphragm. 

The anterior surface of the liver is applied to the inferior sur- 
face of the diaphragm, which separates it from the lower ribs and 
their cartilages upon the right and left sides, Avhile in the median 
line it comes into direct contact with the anterior abdominal wall 
in the subcostal angle. 

The right and posterior surfaces of the liver are in contact with 
the inferior aspect of the diaphragm, which separates the liver 

549 



550 



PHYSICAL DIAGNOSIS 



from the right pleural cavity and the lower border of the right 
lung. 

The inferior surface of the liver, directed somewhat posteriorly 
and toward the left, is in relation with the stomach, the hepatic 
flexure of the colon, the right kidney and suprarenal capsule, 
the second portion of the duodenum and the gall bladder. 




i 



Fig. 



231. — The right upper abdomen. The site o£ the gall bladder, the area of particular 
interest in this region is indicated by the letters G.B. (From Crossen.) 



The hepatic parenchyma is enclosed in a fibrous capsule, which 
is in turn invested with peritoneum with the exception of a limited 
portion of the posterior surface of the liver, constituting the 
"bare area" of the organ, which is united to the inferior surface 
of the diaphragm by areolar tissue. During the course of inflam- 



EXAMINATION OF THE LIVER AND GALL BLADDER 551 

matory disease of the organ the serous investment occasionally 
becomes rugose and roughened with the production of a peritoneal 
friction sound upon the respiratory movements of the organ or 
upon manipulation of the abdominal wall in the hepatic region. 

In addition to the coronary ligament, the liver is retained in 
position by the falciform ligament, the round ligament, and two 
lateral ligaments. The falciform ligament is a broad fold of 
peritoneum which is attached on the one hand to the inferior sur- 
face of the liver at the umbilical notch, and upon the other hand 
to the inferior surface of the diaphragm and to the posterior sur- 
face of the sheath of the rectus muscle as low as the umbilicus. 
The round ligament is a small fibrous cord representing the rem- 
nants of the umbilical vein after it has undergone occlusion. It 
passes from the umbilicus in the free margin of the falciform lig- 
ament to the umbilical notch of the liver, whence it passes along 
the umbilical fissure upon the inferior surface of the liver, to be 
continued upon the posterior surface of the organ as the imper- 
vious ductus venosus up to the inferior vena cava. The lateral 
ligaments attach the extremities of the liver to the inferior sur- 
face of the diaphragm, being largely composed of the lateral re- 
flections of the coronary ligament. 

The liver is supported in the abdominal cavity partially by 
virtue of its ligamentous connections with the abdominal walls, 
partially by an areolar attachment to the inferior aspect of the 
diaphragm in the *^bare area" of the posterior surface of the 
organ, and partially by the pressure which is exerted upon the 
organ by the other abdominal viscera. In the event of relaxation 
of the hepatic ligaments, the liver falls downward to occupy a 
lower level in the abdominal cavity ; and in the presence of gen- 
eral visceroptosis the liver shares in the descent of the abdominal 
viscera. 

The liver is movable within certain limits. Owing to its accu- 
rate apposition with the inferior surface of the diaphragm, it 
participates in the respiratory excursions of this muscle, descend- 
ing during inspiration and ascending during expiration. The 
weight of a right-sided pleural effusion or the pressure exerted in 
right pneumothorax is equally capable of depressing the liver and 
causing its sharp inferior border to project below the right costal 
arch. 

The habitual wearing of tight clothing exercises a distinct 
influence upon the form and the position of the liver. There is 
under these circumstances a progressive flattening of the superior 



552 



PHYSICAL DIAGNOSIS 



surface of the organ with a concomitant lengthening of the right 
lateral surface upon which is frequently noted a constriction 
corresponding to the edge of the costal arch, the tapering lower 
extremity of the right lobe in this state constituting Riedel's lobe. 

The portal vein and hepatic artery enter the transverse fissure 
of the liver between the layers of the gastrohepatic omentum, 
which unites the liver with the stomach. The hepatic duct, in 
close relation with these vessels, passes downward from the trans- 
verse fissure between the layers of the same omentum. 

The gall Madder, the reservoir for the bile, reposes in a shallow 



DIAPHRAGMATIC 
GROOVE 




COSTAL GROOVE 



LOBE OF 
R}EDLL_ 




Fig. 232. — Corset liver. 

depression upon the inferior surface of the right lobe of the liver, 
the tip of the fundus meeting the anterior abdominal wall in the 
notch upon the inferior border of the liver situated at the junction 
of the ninth right costal cartilage with the outer border of the 
right rectus muscle. 

The gall bladder is a pear-shaped sac which is approximately 
four inches in length and one and one-half inches in diameter 
when moderately distended. From the fundus of the sac, the body 
tapers to form the neck, which in turn terminates in the cystic 



EXAMINATION OF THE LIVER AND GALL BLADDER 553 

duct, which unites with the hepatic duct to form the common bile 
duct. 

The common bile duct, the common excretory duct of the liver 
and the gall bladder is approximately three inches in length. It 
descends in the folds of the lesser omentum, passing behind the 
first portion of the duodenum, and passing between the head of 
the pancreas and the descending portion of the duodenum, it emp- 
ties its contents into the second portion of the duodenum usually 
by a common orifice with the pancreatic duct. As a result of the 
relations of the common bile duct to the pancreatic head and the 
descending portion of the duodenum, stenosis of the duct fre- 
quently ensues in the event of malignant disease of the head of 
the pancreas with the production of hepatic enlargement and 
icterus. Stenosis of the duct may also ensue as the result of the 
lodgment of gallstones along its course. In the event of the im- 
paction of a large gallstone at the common orifice of the common 
bile duct and of the pancreatic duct, it has been demonstrated 
that the pressure of the bile in the common duct is capable of over- 
coming the pressure in the pancreatic duct, with the result that 
bile accumulates in the pancreatic duct, perhaps with the pro- 
duction of inflammation of the pancreas. 

Surface Topography. — The superior border of the liver cor- 
responds to the level of the lower border of the sixth rib in the 
midclavicular line, the lower border of the eighth rib in the mid- 
axillary line, and the lower border of the tenth rib in the scapular 
line. 

The inferior border of the liver corresponds to a line drawn 
downward and toward the right from the lower border of the 
sixth rib in the left midclavicular line, the point upon the sur- 
face corresponding to the left extremity of the organ, the line 
crossing the left costal arch at the eighth costal cartilage, the 
median line four inches below the ensiform cartilage, the right 
costal arch at the ninth costal cartilage, the lower border of the 
tenth rib in the midaxillary line, and the lower border of the 
eleventh rib in the scapular line. 

Physical Examination. — Inspection. — Inspection of the hepatic 
region of the abdomen is practiced to the best advantage with the 
subject in the upright or sitting posture; and the examination 
should be conducted under oblique illumination of the abdominal 
wall. The examiner assumes a position to the right side and a 
little distance in advance of the subject, and studies the contour 
of the right hypochondriac region during deep inspiration on the 



554 PHYSICAL DIAGNOSIS 

part of the patient. In the normal adult subject this region of 
the abdomen will not be observed to present any departure from 
the aspect of the opposite side so long as the liver is of normal 
volume and is maintained in its normal habitat. In the child, on 
the contrary, in whom the liver is uncommonly large in propor- 
tion to the dimensions of the adult organ, it is not infrequently 
observed that a furrow rises and falls with the movements of 
expiration and inspiration, which indeed may descend to the level 
of the umbilicus in this class of subjects. When this furrow is 
observed in the adult male, it is significant of downward displace- 
ment of the liver or of enlargement of the organ. 

Any extensive degree of enlargement of the liver is manifested 
by undue prominence of the right costal margin with fullness in 
the right hypochondriac and the epigastric regions, which, in 
cases of excessive hepatic enlargement may extend to the entire 
anterior abdominal wall. Under these circumstances it is, as a 
rule, easy to perceive an inspiratory depression and an expiration 
elevation of the inferior border of the organ. It is very important 
to observe that in the case of flaring of the lower right costal 
arch as a result of hepatic enlargements the intercostal spaces are 
not obliterated, and that they can be readily palpated throughout 
their entire extent; whereas in the event of flaring of the costal 
arch as the result of an extensive pleural effusion the interspaces 
are obliterated. In the case of pleurisy with effusion the intra- 
thoracic excess of pressure is exerted in a direction downward 
and outward, whence it follows that the lower costal arch is un- 
duly prominent, while the ribs and intercostal spaces conform to 
their normal courses; whereas in the case of protrusion of the 
costal arch from hepatic enlargement the intraabdominal pressure 
is exerted in a direction upward and forward with the result that 
the lower ribs undergo an abnormal torsion, their internal sur- 
faces becoming inferior and their external surfaces being directed 
superiorly. 

In interpreting respiratory mobility of tumors arising in the 
upper abdominal cavity, the examiner should bear in mind that 
growths of the liver and of the spleen alone possess a true res- 
piratory mobility; that respiratory excursions are always more 
pronounced upon the side of the liver on account of its more in- 
timate relation to a more extensive surface of the inferior aspect 
of the diaphragm; and that respiratory movement is only im- 
parted to growths of the stomach or intestine when these latter 
have contracted adhesions with the liver or with the spleen, which 



EXAMINATION OF THE LIVER AND GALL BLADDER 555 

result in the transmission of false respiratory movements to these 
growths. 

The detection of mobile excursions of the inferior border of 
the liver below the right costal arch does not, however, point in- 
variably to enlargement of the organ. The abnormally low posi- 
tion of this sharp margin of the organ may be due to displacement 
downward of the liver by an increase in the intrathoracic pressure 
which is exerted upon the superior aspect of the diaphragm, or 
it may be due to a falling of the liver as the result of relaxation 
of its suspensory ligaments. 

Of these two factors, the former operates with the greater fre- 
quency in the production of depression of the liver. In the pres- 
ence of extensive effusion into the right pleural sac in sero- 
fibrinous pleurisy, in the event of the development of hydro- or 
pyopneumothorax, in the course of an extensive pericardial effu- 
sion, or as the result of the progressive development of neoplasms 
in the mediastinum, the liver is forced downward in the abdominal 
cavity and its inferior border becomes perceptible below the right 
costal arch. Kelaxation of the hepatic ligaments, permitting the 
liver to fall to an abnormally low level in the abdominal cavity, 
is encountered most frequently in multiparse in whom successive 
pregnancies have caused general relaxation of the abdominal 
walls, and hepatoptosis in these cases is often merely part and 
parcel of general visceroptosis. 

Only occasionally is it possible upon inspection of the respira- 
tory excursions of an enlarged liver to detect local protrusions 
of the inferior border of the organ, which are in some instances 
produced by a solid tumor of the organ, in other cases are due to 
abscess, and yet again to cystic tumors of the organ. Also, occa- 
sionally in the course of hepatic abscess or neoplasm adhesions 
form between the liver and the abdominal wall, with the con- 
sequent participation of the latter in the morbid state of the liver. 
In these instances one occasionally encounters in the hepatic area 
a circumscribed protrusion of the ventral abdominal wall which 
may be the site of fluctuation or which may be discolored and sen- 
sitive to pressure. 

A local protrusion below the right costal arch at the junction 
of the ninth right costal cartilage with the outer border of the 
right rectus muscle is frequently encountered in distention of the 
gall bladder with bile, serous fluid, or purulent material. Sim- 
ilarly, in the presence of carcinoma of the gall bladder the nodu- 
lar rigid wall of the viscus frequently causes circumscribed prom- 



556 PHYSICAL DIAGNOSIS 

inence in this area. A distended gall blacfder retains in general 
the original contour of this viscns, and presents upon inspection 
a circumscribed pyriform elevation of the abdominal wall. The 
fundus of the gall bladder under these circumstances may be 
encountered as low as the umbilicus. 

When a large protrusion is encountered in the lower anterior 
and lateral portions of the hepatic area, the examiner should bear 
in mind the possibility of the existence of a corset liver in the 
female subject. This deformity of the liver may extend even to 
the level of the iliac crest ; and when it is overlapped by coils of 
intestine, it may readily be mistaken for a new growth springing 
from the right kidney or the ascending colon. 

A visible systolic pulsation of the liver is occasionally noted in 
connection with tricuspid regurgitation, though usually the pulsa- 
tion requires bimanual palpation for its recognition. Similarly, 
in the case of the enlarged liver, the systolic pulsation of the sub- 
jacent abdominal aorta may be imparted to the liver, when it is 
manifested in the form of a simple rising and falling of the organ 
and not in the form of a true expansile pulsation. A transmitted 
impulse conveyed to the liver by the impact of an over-acting 
heart should not be mistaken for a true pulsation of the liver. 

Palpation. — In practicing palpation of the inferior hepatic 
border the patient should assume the dorsal decubitus with the 
knees drawn up and supported. The examiner, seated upon the 
right side of the patient, should place the finger-tips of the right 
hand upon the abdominal surface immediately below the right 
costal arch, and by gradually sinking the finger-tips into the ab- 
dominal wall, should seek for the lower margin of the liver. If it be 
found that the liver projects below the costal margin, the examiner 
should apply both hands flat upon the abdomen, and by downward 
pressure cause the finger-tips to glide over the exposed portion of 
the liver, searching for tenderness, any abnormality in contour, 
and investigating the consistence of the organ. 

In the normal adult subject the inferior border of the liver will 
not be encountered below the costal arch in the male subject. In 
the female subject, on the contrary, as the result of the habitual 
use of clothing which constricts the lower portion of the thorax, 
the inferior border of the liver not infrequently occupies a position 
below the right costal margin. In multipar^e the relaxation of the 
abdominal walls and of the suspensory ligaments of the liver tends 
further to produce lowering of the liver in these subjects. In 



EXAMINATION OF THE LIVER AND GALL BLADDER 



557 



young* children the inferior border of the liver is very frequently 
encountered below the costal margin. 

If the inferior margin of the liver is not encountered below the 
costal margin, the examiner should place the finger-tips of both 
hands upon the abdominal surface just below the costal arch and 
should press inward and upward beneath the costal arch as far as is 
possible. The subject is directed to inspire deeply, when during 
inspiration the liver will be felt to descend with the descent of 
the diaphragm and to become palpable at the completion of inspira- 
tion. By the procedure first described an enlarged liver or a de- 
pressed liver will be revealed projecting below the costal arch; 
while, by the second maneuver, a normal or contracted liver may 
frequently be palpated. 




Fig. 233. — Indicating the site for tenderness or a mass due to disease of the gall 
bladder. It may be found anywhere from the point indicated downward and outward 
to the margin of the ribs on the right side. (From Crossen.) 

The facility with which the liver is palpated is markedly in- 
fluenced by the state of the abdominal walls. An excessive deposi- 
tion of fat in the walls impedes and occasionally renders quite 
unsatisfactory the exploration of the liver by palpation. In the 
multipara, on the contrary, with relaxation of the abdominal walls 
and with possible diastasis of the recti, the manual exploration of 
the organ is rendered so much the more easy. 

Similarly, the presence of gas or fluid in the intestinal tract or 
in the abdominal cavity is a frequent cause of confusion in pal- 
pation of the liver. In the presence of ascites, which is so often due 
to hepatic affections and renders a careful palpation of the organ 



558 PHYSICAL DIAGNOSIS 

SO desirable, the examiner is occasionally abfe to reach the inferior 
border of the liver by exercising a few rather sharp, jerky pal- 
pating movements toward the lower border of the organ, which 
by crowding the fluid aside enables him to reach the liver. In this 
class of patients the examination is further facilitated by placing 
the patient in the left lateral decubitus or in the genupectoral 
position. In the case of ascites of suspected hepatic origin, the 
fluid should be evacuated from the abdominal cavity, whereupon 
palpation of the liver becomes very easy and is apt to reveal some 
very striking findings. 

Enlargement of the liver accompanies the acute infectious fevers, 
fatty infiltration of the organ, chronic passive congestion of the 




Fig. 234. — Palpation of liver. 

organ, and amyloid disease of the liver. Similarly, hepatic enlarge- 
ment attends Weil's disease, hepatic abscess, carcinoma or gumma 
of the organ, leukemia, hypertrophic hepatic cirrhosis, echinococcus 
cyst, and Banti's disease. 

In every case in which enlargement of the liver is suggested 
by the finding of a palpable inferior margin of the liver, the 
examiner should continue the examination in the effort to determine 
the state of the surface of the liver, the consistence of the organ, 
the presence of sensibility of the liver, and the respiratory mobility 
of the mass. 



EXAMINATION OF THE LIVER AND GALL BLADDER 559 

When the inferior border of the liver is appreciated by the 
palpating hand, it may be fonnd to be smooth or to be irregular and 
the site of nodular elevations and depressions. When a smooth 
surface is encountered, the examiner should proceed to identify 
it with the liver by establishing upon its surface the two notches of 
the inferior hepatic border, the one approximately one inch to the 
right of the median line and the second at the outer border of the 
right rectus muscle. 




1 



";^im^ 



.^.^ 






;n 




Fig. 235. — Hepatic enlargement due to carcinoma of head of pancreas. R, right lobe of 
liver; L, left lobe of liver; G, distended gall bladder. (From Eisendrath.) 

An irregular, nodular hepatic surface is encountered in carcinom- 
atous infiltration of the liver, in atrophy of the organ of syphilitic 
or nonspecific origin, and in echinococcus disease of the organ. The 
nodules of carcinoma present a central umbilication, which can oc- 
casionally be appreciated in palpation of the liver through a thin 
abdominal wall. The nodules of the syphilitic liver are uniformly 
small, whereas the irregularity of the liver in the case of echinococ- 



560 



PHYSICAL DIAGNOSIS 



cus disease takes the form of a few protrusions of relatively ex- 
tensive dimensions. 

The palpable consistence of the liver occasionally gives a cine 
to the nature of the cause of the enlargement. The fatty liver pos- 
sesses a consistance scarcely altered from that of the normal organ, 
while that of chronic passive congestion scarcely offers any more 
resistance. In the case of amyloid disease of the liver, on the con- 
trary, the organ frequently attains a woody hardness. Carcinom- 
atous infiltration of the liver produces a liver of hard consistence. 
In the case of hepatic abscess and echinococcus cyst the consistence 
of the mass is softened and fluctuation is frequently obtained under 




Fig. 236. — Dorsal pressure point in cholelithiasis. 



these circumstances. Frerichs has found echinococcus disease of the 
liver, however, associated' with the development of multilocular 
cysts of the organ, in which the liver possessed a consistence almost 
cartilaginous, suggesting strongly carcinomatous infiltration of the 
organ. Jaccoud has encountered fluctuation of the liver in certain 
cases of hypertrophic cirrhosis of the organ. 

Sensihility of the liver, manifested by pain upon pressure, may 
be diffuse or may be circumscribed to certain definite regions of the 
abdomen. Diffuse sensibility of the liver is encountered in fatty 
degeneration and chronic passive congestion of the organ, in hyper- 



EXAMIXATIOX OF THE LIVER AND GALL BLADDER 



561 



trophic cirrhosis, in hepatic abscess and carcinoma, and in inflam- 
matory disease involving the peritoneal covering- of the organ in 
perihepatitis. Circumscribed sensibility is usually significant of 
affections of the gall bladder, the tenderness of an acutely inflamed 
gall bladder manifesting itself upon pressure over the fundus of 
this viscus at the junction of the ninth right costal cartilage and 
the outer border of the right rectus muscle. Similarly cholelithiasis 
is attended besides by a tender point upon pressure immediately to 
the right side of the twelfth dorsal vertebra posteriorly. 

The respiratory mobility of the inferior border of the liver, which 
was described under inspection, can be readily detected upon pal- 
pation of the inferior border of the organ. During inspiration this 




Fig. 237. — Palpating for general tenderness of the liver. (From Crossen.) 

border of the organ descends, only to ascend to a corresponding de- 
gree during expiration. The respiratory mobility of masses of 
hepatic origin is a valuable sign in differentiation from similar 
masses springing from the stomach, intestine, kidney, or pancreas. 
But while the growths springing from the liver and from the 
spleen alone among intraabdominal growths possess a true respira- 
tory mobility, it does not follow that all hepatic growths are mobile. 
The presence of extreme tympanites or ascites impairs or prevents 
the respiratory mobility of certain hepatic enlargements. Simi- 
larh', when an enlarged liver has established firm adhesions with 
the abdominal walls, respiratory mobility of the organ is abolished. 
Also as inflammatory disease of the liver is very frequently ac- 



562 



PHYSICAL DIAGNOSIS 



companied by inflammation of its peritonea! investment, the pa- 
tient in the presence of this affection frequently volitionally in- 
hibits the respirations, with consequent abolition of the respiratory 
mobility of the liver. In the presence of extreme enlargement of 
the liver, moreover, the prolonged pressure of the enlarged organ 
upon the right vault of the diaphragm is capable in certain in- 
stances of provoking atrophy of this muscle, with consequent 
abolition of respiratory mobility of the liver. 

Occasionally one can appreciate a tactile fremitus upon palpa- 
tion of the abdominal wall over a liver which is the seat of peri- 
hepatitis; but this finding is very inconstant, and it is more 




Fig. 238. — Showing tlie site for tenderness of the left lobe of the liver. (From Crossen.) 



common to detect friction of the roughened peritoneal surfaces 
upon auscultation than it is to detect the fremitus during pal- 
pation. 

Tumors and enlargements of the gall bladder deserve particu- 
lar attention during the palpation of the liver. The normal gall 
bladder is difficult of detection upon palpation; but when the 
liver is depressed and the stomach and intestine are empty, one 
can occasionally palpate the normal gall bladder. When the 
viscus is distended or is the seat of carcinomatous infiltration, it 
is palpated readily; but here again a confusing element may be 
added to the examination by the insinuation of the transverse 
colon between the enlarged fundus of the gall bladder and the 



EXAMINATION OF THE LIVER AND GALL BLADDER 563 

inferior border of the liver, in such a fashion that the distended 
gall bladder assumes the form of a mass independent of the liver 
upon palpation and percussion. In addition to respiratory mo- 
bility, the distended gall bladder presents a distinct lateral 
mobility upon palpation. 

Occasionally v^hen the gall bladder contains multiple stones, a 
sensation of crepitation is appreciated upon palpation of the 
fundus of the viscus. 

The palpation of the hepatic region should not be considered 
complete until the examiner has practiced bimanual palpation of 
the liver v^ith the view of detecting true expansile pulsation of 
the organ in the presence of tricuspid insufficiency. 

Ferciission. — In practicing percussion of the hepatic area the 
student succeeds in establishing two gradations of dullness due to 
the presence of the liver in the upper and right segment of the 
abdomen below the lower ribs and intercostal spaces. These areas 
constitute respectively the areas of hepatic dullness and of hepatic 
flatness. 

The Areas of Hepatic Dullness and Flatness. — Upon percussing 
downward over the surface of the thorax and abdomen in the mid- 
clavicular, midaxillary, and scapular lines from an area of frank 
vesicular resonance, the percussion note will become impaired or 
dull when the point is reached where the superior limit of the liver 
is covered by the pulmonary tissues. The point of change in the 
quality of the note indicates the upper limits of the area of hepatic 
dullness. The superior limits of this area are encountered at the 
upper border of the fifth rib in the right midclavicular line, the 
seventh intercostal space in the right midaxillary line, and at the 
eighth intercostal space in the right scapular line. 

Upon continuing the percussion downward along these lines, 
substituting light for forcible percussion, a point is reached in 
which the dullness gives place to flatness, indicating the upper limit 
of the region where the liver is in direct contact with the abdom- 
inal wall, the superior limit of the area of hepatic flatness. The 
superior limits of this area are found in the normal adult subject 
at the lower border of the sixth rib in the right midclavicular line 
of the eighth rib in the right midaxillary line, and of the tenth rib 
in the right scapular line. 

If now the percussion is continued downward along the same 
lines, the flat note Avill be replaced by intestinal tympany when 
the inferior limit of the liver is attained. The points of change 
indicating the inferior limit of the area of hepatic flatness are 



564 PHYSICAL DIAGNOSIS 

encountered at the ninth rib in the right' inidclavicular line, the 
tenth rib in the right midaxillary line, while in the right scapular 
line the flatness of the liver is continuous with that produced 
by the kidney. 

The inferior limit of the area of hepatic flatness in the epi- 
gastric region lies three to four inches below the ensiform cartil- 
age. Thus, it is observed that the areas of hepatic dullness and 
flatness extend downward and toward the right; that posteriorly 
they are continuous with the flatness of the right kidney; and 
that anteriorly they blend with the right border of the area of 
cardiac dullness. 

In pathologic states the hepatic dullness may be abolished, 
may be diminished in extent, may be increased in extent, or the 
area of dullness as a whole may be displaced from its normal site. 

Absence of hepatic dullness upon percussion of the hepatic area 
is significant of falling of the liver, in which event the dullness 
of this organ is replaced by intestinal tympany. This state, which 
is usually encountered in multipar^e as a result of extreme re- 
laxation of the suspensory ligaments of the liver, may permit the 
liver to occupy the iliac fossa, constituting the '^floating liver" 
of Cantani. In this abnormal situation the liver could readily be 
confused with an abdominal tumor. In this connection it is to be 
remembered that the displaced liver occupies in the main the 
right half of the abdominal cavity; that its superior surface is 
convex, smooth, and rounded ; and that palpation of its inferior 
sharp margin reveals the presence of the two notches which exist 
upon this border of the organ. Winckler and Sutugin have suc- 
ceeded, during palpation of a displaced liver, in outlining the 
suspensory ligaments of the organ and in tracing them to their 
connections with the lateral abdominal walls. The displaced 
liver can usually be restored to its normal habitat by manual 
manipulation, whereupon the intestinal tympany is replaced 
by hepatic dullness in that region. 

When tympanites is present in a pronounced degree, the liver 
is not infrequently crowded upward into the right vault of the 
diaphragm and percussion of the hepatic area under these cir- 
cumstances yields only mediocre dullness in comparison with the 
excessive tympanicity of the percussion note over adjacent por- 
tions of the abdomen. Similarly when the liver and inferior 
diaphragmatic surface have contracted adhesions which exert 
traction upon the superior surface of the organ, the area of he- 
patic dullness is very much restricted and occasionally is outlined 



EXAMIXATIOX OF THE LIVER AXD GALL BLADDER 565 

with difficulty if indeed at all. Also in transposition of tlie 
viscera, when the spleen occupies the right upper quadrant of 
the abdominal cavity and the liver lies in the upper left quadrant, 
the area of hepatic dullness is defective. As a rule in these cases 
the thoracic viscera are also transposed, the cardiac apex lying 
upon the right side of the sternum; but Mosler has encountered 
cases in which the transposition of the viscera was limited solely 
to the liver and the spleen. 

Diminution of hepatic dullness is encountered in all cases of 
diminution in the dimensions of the liver ; but it would be errone- 
ous to immediately conclude that the liver has diminished in vol- 
ume in every case in which there is a restriction of the area of 
hepatic dullness. Before definite conclusions may be formulated 
in respect to the dimensions of the liver, it is necessary to estab- 
lish the absence of certain conditions which may simulate a dim- 
inution in the volume of the liver. Occasionally the large in- 
testine insinuates itself in front of the lower border of the liver, 
simulating a diminution in volume of this organ. In these cases 
it is necessary to endeavor by forcible compression with the 
pleximeter to reach the subjacent hepatic surface and to obtain 
hepatic dullness through the tympanitic superjacent colon. Simi- 
larly, in the presence of Avell established hypertrophic emphysema, 
the lower border of the right lung is extended and comes to over- 
lie a greater area of the anterior and lateral hepatic surfaces, 
thus simulating a diminution in the volume of the liver. Extreme 
tympanites acts similarly in masking the true level of the inferior 
border of the area of hepatic flatness. Similarly all conditions 
which are attended by increase of general intraabdominal pres- 
sure, such as ascites, a large tumor of the intestine or an ovarian 
cyst, by forcing the liver upward into the vault of the diaphragm 
cause a pseudcdiminution in the volume of the liver as outlined by 
percussion. 

Diminution of the area of hepatic dullness attributable to dim- 
inution of the volume of the liver is encountered in acute yellow 
atrophy, atrophic hepatic cirrhosis, and hepatic atrophy consecu- 
tive to obliteration of the biliary passages. In the case of acute 
yellow atrophy there is produced during the course of a fcAv days 
a very notable diminution in the volume of the liver, which is 
contracted into a small pulpy mass adjacent to the A^ertebral 
column and covered by coils of the small intestine. In the case 
of atrophic hepatic cirrhosis the retraction of the gland is first 
noted in the left lobe, which is retracted toward the right, with 



566 PHYSICAL DIAGNOSIS 

the production of a gastrocardiac limit of*the semilunar space of 
Traube, which comes to intervene between the gastropulmonary 
and gastrohepatic limits of this area of frank gastric tympany. 
This form of hepatic cirrhosis is usually attended by enlargement of 
the spleen and ascites. In hepatic atrophy consecutive to obliter- 
ation of the biliary passages, the diminution in volume of the 
liver is preceded by a transient hypertrophy of the organ, and 
is accompanied by chronic icterus. 

Increase of the area of hepatic dullness is encountered in the 
presence of hypertrophic cirrhosis and in degeneration of the 
organ, in the presence of hepatic tumor or abscess, and in simple 
congestion of the organ. From the clinical standpoint it is desir- 
able to distinguish two varieties of hepatic hypertrophy ; namely, 




\ 
\ 

\ 



Fig. 239. — Indicating the region for dullness from enlarged liver. (From Crossen.) 

hypertrophy in which the liver preserves its normal contour, and 
hypertrophy of the organ which develops irregularly, with the 
presence of abnormal protrusions upon the hepatic surface. 

A generally enlarged liver with maintenance of the normal 
contour is encountered in the hypertrophic cirrhosis of Hanot. 
A similar regular enlargement of the liver, but which is not 
frequently attended by jaundice, is encountered in fatty infiltra- 
tion and chronic passive congestion of the liver in its earlier 
stages, in chronic malarial intoxication, during the acute infec- 
tious fevers, and in diabetes and amyloid disease of the liver, as 
well as in Banti's disease. 

Irregular hypertrophy of the liver, with alteration of the nor- 
mal contour of the organ in the form of multiple nodules upon the 



EXAMIXATIOX OF THE LIVER AXD GALL BLADDER 567 

surface or a single extensive protuberance of the surface of the 
organ, is encountered in connection with carcinomatous infiltra- 
tion of the liver, syphilis of the liver, hepatic abscess, or hydatid 
disease of the liver. 

While increase in the volume of the liver results in extension 
of the areas of hepatic dullness and flatness, it is to be borne in 
mind that not every extension of these areas is symptomatic of 
hepatic enlargement. In all cases in which the inferior limit of 
the area of hepatic flatness is extended, the superior limit of 
hepatic dullness should be carefully delimited as well as the left 
sharp extremity of the left lobe of the organ above Traube's 
semilunar space. In true hepatic hypertrophy the area of hepatic 
dullness is extended in one or all of its dimensions. AVhen the 
lower limit is established, the examiner should proceed to the de- 
limitation of the superior limit with a view to the determination 
whether this limit occupies its normal level, whether it is ele- 
vated, or whether it is lowered, indicating in the last instance a 
depression of the organ rather than hypertrophy. In true en- 
largement of the liver the left extremity of the left lobe of the 
organ extends ordinarily well over into the left hypochondriac 
region, it may be to impinge against the spleen, with the conse- 
quent obliteration of the gastropulmonary limit of the semilunar 
space of Traube. 

A pseudoextension of hepatic dullness superiorly is produced 
in the case of extensive effusion into the right pleural sac, in 
which cATut the continuous dullness may be confused with an ex- 
tension of hepatic dullness upward, such as not infrequently 
attends hydatid cyst of the liver. The examiner should be cir- 
cumspect in the differential diagnosis of these two states and 
should bear in mind the principle laid down by Frerichs; namely, 
that in the case of hydatid disease of the liver the superior limit 
of the zone of dullness presents its convexity superiorly, whereas 
in the event of pleurisy with effusion, the dullness presents an 
inferior convexity. A right-sided lobar pneumonia is cpiite as 
likely to cause confusion in the establishment of the superior limit 
of the hepatic dullness in any case in which hepatic enlargement 
under these circumstances is suspected. In the latter event the 
examiner should seek for bronchial respiration, rales, and in- 
creased vocal fremitus over the upper regions of the dull area. 

A pseudoextension of hepatic dullness downward and toward 
the left may be encountered when the stomach and intestines 
contain solid material or when they are the seat of neoplasm. In 



568 PHYSICAL DIAGNOSIS 

the first instance evacuation of the gastrointestinal canal clears 
the confusing signs; while in the second case the examiner should 
resort to methodical palpation of the epigastrium and to ausculta- 
tory percussion of the various organs in the effort to differentiate 
the site of the growth, if any be present. Tumors of the stomach 
or intestine upon this examination are mingled with intestinal 
tympany and reveal amphoric phenomena, both of which are ab- 
sent in the case of growths springing from the liver. 

Finally, in any case in which it is a question of differentiation 
of collections situated above and below the diaphragm, free 
resort should be had to fluoroscopy in the differential diagnosis. 

Displacement of the Liver. — As stated in a previous paragraph, 
instead of being increased in extent in one or more of its dimen- 
sions, the area of hepatic dullness may be displaced in its entirety. 
This displacement is usually manifested in a vertical direction. 

Downward displacement of the liver may be occasioned by the 
pressure upon the superior aspect of the diaphragm by hyper- 
trophic emphysema, pneumothorax, right-sided pleurisy with 
effusion, cardiac hypertrophy, or large pericardial effusion. 
Similarly, the liver may be depressed by a subphrenic abscess. 
Finally, the liver may participate in a general visceroptosis and 
occupy a lower level in the abdominal cavity than is normal. In 
the case of the ''floating liver" of Cantani, occurring in multi- 
parge, the liver may occupy the right iliac fossa. 

Downward displacement of the liver is differentiated from an 
increase in volume of the organ by demonstrating by percussion 
that the superior limit of hepatic dullness occupies a lower level 
than is normal. 

Upward displacement of the liver occurs as a result of pressure 
exerted upon the inferior surface of the organ by ascites, tym- 
panites, or increased abdominal tension due to tumor of an ab- 
dominal organ or ovarian cyst. Upward displacement may, 
however, be the sequence of diminished intrathoracic tension such 
as occurs with fibroid retraction of the right lung; or it may be the 
result of paralysis of the diaphragm. In upward displacement of 
the liver it may be demonstrated by percussion that both the 
superior and inferior limits of hepatic dullness are elevated and 
not the superior limit alone. 

Auscultation. — Auscultation over the hepatic area occasionally 
elicits a friction sound in connection with peritoneal involvement 
in the course of perihepatitis. In cases of cholelithiasis, gall- 



EXAMINATION OF THE LIVER AND GALL BLADDER 569 

stone crepitations have been elicited upon auscultation over the 
fundus of the gall bladder. 

Leopold, Martini, and Gabbi have described vascular murmurs 
upon auscultation of the liver in the presence of hepatic carci- 
noma and sarcoma, and in hepatic cirrhosis in which the blood 
vessels of the liver are constricted at several points in their 
course. Similar murmurs have been described in the presence of 
aneurysm of the hepatic artery. 

Eustis has encountered bronchophony upon auscultation of the 
hepatic region in the presence of hepatic abscess which had per- 
forated the diaphragm and established a bronchial communi- 
cation. 



CHAPTER XXV 

EXAMINATION OF THE SPLEEN, KIDNEYS, BLADDER 
AND URETERS 

EXAMINATION OF THE SPLEEN 

Clinical Anatomy. — The spleen is a solid organ situated deeply 
in the left hypochondriac region. The organ occupies an oblique 
position in the abdominal cavity, between the fundus of the 
stomach, the left kidney, and the diaphragm, its long axis corre- 
sponding to the course of the tenth rib. Owing to its accurate ap- 
position with the inferior aspect of the diaphragm, the spleen 
exhibits respiratory mobility, and also a certain range of mobil- 
ity with changes in the bodily posture. 

While the normal spleen is subject to certain variations in form, 
its usual contour is elongated with a considerable degree of flat- 
tening; and when the spleen assumes this form it presents three 
surfaces; namely, a diaphragmatic surface, a gastric surface, and 
a less extensive renal surface. The diaphragmatic surface of the 
spleen is closely applied to the inferior surface of the left vault 
of the diaphragm, which separates the organ from the pleural 
cavity and the lower border of the left lung between the ninth, 
tenth, and eleventh ribs. The gastric surface of the spleen, di- 
rected forward, inward, and downward, is in relation with the 
fundus of the stomach. The renal surface of the spleen, directed 
inward and downward, is the least extensive of the three surfaces 
of the organ. It is in relation with the outer aspect of the supe- 
rior pole of the left kidney and occasionally with a portion of the 
left suprarenal capsule. 

The superior or posterior extremity of the spleen is on a level 
with the eleventh thoracic vertebra, and occupies a position one 
and one-half inches from the midspinal line. The inferior or an- 
terior extremity of the organ reaches the midaxillary line, and 
occasionally the anterior axillary line in the normal subject. 
The anterior extremity of the spleen commonly reaches as far 
forward as the costoarticular line, which is a diagonal line erected 
upon the anterolateral wall of the trunk from the anterior extrem- 
ity of the eleventh left rib to the left sternoclavicular articula- 
tion. Projection of the anterior extremity of the spleen beyond 

570 



EXAMINATION OF THE SPLEEN 571 

this line is indicative of enlargement or displacement of the organ. 

The spleen is maintained in its normal habitat through the 
medium of the splenic ligaments, composed of folds of peritoneum, 
and by the intraabdominal tension exercised upon its inferior 
surface, and counterbalanced by the intrathoracic tension exer- 
cised upon the superior aspect of the diaphragm. 

The spleen is invested by a fibrous capsule and by a superjacent 
investment of peritoneum, save at the hilum of the organ situated 
upon the margin intervening between the gastric and the renal 
surfaces of the organ, at which point the splenic vessels enter and 
leave the organ. In the presence of inflammation of the organ 
the peritoneal coat frequently becomes roughened and rugose, 
with the production of the peritoneal friction sounds of Beatty- 
Bright. Moreover, as the splenic vein forms one of the principal 
tributaries of the portal vein, in the presence of valvular disease 
of the heart, or in portal obstruction from hepatic cirrhosis, the 
spleen becomes the seat of passive congestion with enlargement 
of the organ. 

The size and weight of the spleen present numerous variations at 
different periods of life and under varying circumstances in the 
adult subject. The normal adult spleen is approximately five inches 
in length, three inches in breadth, and one inch in thickness. The 
spleen exhibits a moderate increase in volume during digestion ; and 
the organ is regularly of ample dimensions in the well nourished 
subject, to become very small during starvation. 

The weight of the spleen in proportion to that of the entire 
body is approximately the same at birth as it is in the case of the 
adult subject. At birth the proportion is 1 :350, while in the 
healthy adult subject it is 1:320 to 1:400. With advancing age, 
however, the organ not only decreases considerably in weight, 
but even decreases considerably in proportion to the general 
weight of the body, frequently falling to the proportion of 1 :700. 

Occasionally in the healthy adult the spleen possesses a roughly 
tetrahedral form, while in other instances it is irregularly quad- 
rilateral, with the result that instead of the long axis of the organ 
conforming to the course of the tenth rib, it occupies a plane per- 
pendicular to this rib. 

The spleen commonly corresponds to an area upon the surface 
of the body extending from the upper border of the ninth rib to 
the lower border of the eleventh rib, its inner extremity being 
situated one and one-half inches from the midspinal line, and its 
anterior extremity reaching as far forward as the midaxillary or 



572 PHYSICAL DIAGNOSIS 

the anterior axillary line. Superiorly tfi^ area of splenic dullness 
is limited by the inferior border of pulmonary resonance of the 
left lung, while inferiorly it is continuous with the area of renal 
dullness. 

Physical Examination.- — Inspection. — Inspection of the abdomen 
with the view of detecting variations in the size and position of 
the spleen is preferably practiced with the subject in the upright 
station or in the sitting posture, though it is occasionally desir- 
able to employ other attitudes which will be mentioned in a sub- 
sequent paragraph. The normal spleen furnishes no evidence of 
its existence upon inspection of the abdominal surface. In the 
presence of enlargement of the organ, even, there is not evidence 
of the hypertrophy upon inspection in every instance. As a gen- 
eral rule the splenic enlargements attending the acute infectious 
fevers are not demonstrable upon inspection, owing partially to 
the fact that the splenic hypertrophy is only moderate in degree, 
and partially to the fact that the consistence of the organ is not 
materially influenced in these states, and while enlarged, it does 
not produce protrusion of the abdominal walls or flaring of the left 
costal arch. It is in chronic hypertrophies of the organ, in which 
the consistence of the organ is increased, that the examiner en- 
counters fullness in the splenic region and flaring of the lower 
left costal arch. This protrusion of the abdominal wall is best 
recognized by the use of oblique illumination. 

If the splenic enlargement is not too extensive, the organ pre- 
sents two varieties of mobility; namely respiratory mobility coin- 
ciding with the movements of respiration, and postural mobility, 
depending upon changes in the attitude of the body for its in- 
duction. When the subject is placed in the right lateral decubitus, 
the tumor is displaced toward the right side of the abdomen, 
while in the left lateral decubitus it falls toward the opposite side 
of the abdominal cavity. Upon assuming the dorsal decubitus the 
splenic tumor ascends to a slight degree, to fall again upon assum- 
ing the erect posture. The respiratory movements of the spleen 
are never as extensive as are those of the liver, as the spleen is 
apposed to the inferior aspect of the diaphragm to a lesser degree 
than is the superior surface of the liver. 

The examiner should make a distinction between acute enlarge- 
ment of the spleen, which is transient and is not attended by ap- 
preciable alteration of the consistence of the organ, and is only 
rarely sufficiently pronounced to produce bulging of the abdom- 
inal wall, and chronic splenic enlargement, which is attended by 



EXAMINATION OF THE SPLEEN 



573 



various degrees of hardening of the spleen, and which is con- 
stantly attended by physical manifestations of the splenic hyper- 
trophy. Acute hypertrophy of the spleen attends many acute in- 
fectious diseases, notably diphtheria, scarlet fever, variola, pneu- 
monia, influenza, acute miliary tuberculosis, typhoid and para- 
typhoid fevers, typhus fever, erysipelas, and septicemia. Chronic 
hypertrophy of the spleen is encountered in connection with 
chronic valvular disease of the heart, atrophic hepatic cirrhosis, 




Fig. 240. — Indicating the area in which to search for splenic tenderness or enlargement. 
When the spleen is diseased it usually becomes enlarged and heavy and sinks below the 
margin of the ribs at the point indicated. (From Crossen.) 

splenomedullary leukemia, lymphatic leukemia, splenic anemia, 
chronic malarial intoxication, Hodgkin's disease, splenic infarc- 
tion, and in amyloid and syphilitic disease of the spleen. In this 
category also come morbid growths of the spleen, such as car- 
cinoma, sarcoma, and cystic disease of the organ. Under these 
circumstances the splenic enlargement is occasionally so exten- 
sive as to largely fill the abdominal cavity and cause confusion in 
differential diagnosis between the spleen and ovarian cyst. 



574 PHYSICAL DIAGNOSIS 

Palpation. — In the normal adult subject with normal abdominal 
walls and with the normal spleen occupying its normal habitat 
beneath the left vault of the diaphragm, palpation of the spleen 
is not possible, in whatever position the subject may be placed. 

The examiner should endeavor in the first instance to palpate 
the spleen with the subject in the dorsal decubitus; after which 
it may become desirable to practice palpation of the organ in the 
right diagonal position of Schuster. 

With the subject in the dorsal decubitus the examiner, seated 
by the left side of the patient, should apply the left hand, rein- 




Fig. 241. — Palpation o£ the spleen. 

forced by the superimposed finger-tips of the right hand flat upon 
the abdomen in such position that the finger-tips of the left hand 
may be inserted beneath the left costal arch. If the spleen is 
enlarged, no difficulty will be experienced in palpating its lower 
border. The normal organ, however, as stated in a preceding 
paragraph, is not palpable. But the failure to encounter the in- 
ferior border of the organ by the above procedure shall not be 
interpreted as proof of the absence of splenic hypertrophy. If 
the spleen has not been encountered by simply sinking the finger- 
tips beneath the left costal arch, the subject is directed to inspire 
deeply. Upon making pressure at the commencement of full in- 



EXAMINATION OF THE SPLEEN 575 

spiration, the lower border of the organ, in the presence of moder- 
ate splenic hypertrophy, will be felt as it descends with the 
diaphragm during inspiration. 

If the spleen is not encountered during this last maneuver, the 
examiner may resort to palpation in the right diagonal posture of 
Schuster. The subject assumes a recumbent posture midway be- 
tween the dorsal decubitus and the right lateral decubitus, at the 
same time elevating the left arm and placing it behind the head. 
When the proper posture is attained, the patient reposes upon 
the right scapula. If now the finger-tips of the examiner are 
insinuated beneath the left costal arch during profound inspira- 
tion, the inferior border of the spleen will frequently become pal- 
pable as it descends. 

Some difficulty may arise in determining whether a palpable 
tumor encountered below the left costal arch is of splenic or renal 
origin. In this connection it should be recalled that the spleen 
moves with respiration, whereas the kidney possesses no respira- 
tory mobility. Moreover, as the kidney is overlapped by the large 
intestine, an enlargement of the kidney pushes the tympanitic gut 
before it, whereas the spleen occupies a position in front of the 
intestine. Finally, the shape of the two organs differs, the spleen 
being more or less oval, elongated, or tetrahedral with a sharp in- 
ferior border, while the kidney is smooth and reniform. Palpa- 
tion is the method of choice in the exploration of variations in the 
contour, size, and position of the spleen. 

During palpation of the spleen the examiner should take note 
of its form, dimensions, consistence, sensibility, mobility, the 
state of the surface, the presence of splenic friction fremitus or 
of pulsations, and the site in which the organ is encountered. 

The hypertrophied spleen may conserve its normal form, or this 
contour may be markedly distorted from the normal, the contour 
of the organ in the two instances offering some indications as to 
the cause of the hypertrophy. The moderate acute enlargements 
of the organ are quite constantly attended by the preservation of 
the normal contour of the organ, as are also the chronic enlarge- 
ments due to diseases of the blood or to chronic valvular disease 
of the heart. In the case of splenic enlargement due to malignant 
disease, to cystic disease, or to abscess of the gland, however, the 
normal contour of the organ is distorted and one or more pro- 
trusions may sometimes be palpated upon its surface. 

The dimensions of the hypertrophied spleen present very numer- 
ous gradations from the moderate acute hypertrophies which are 



576 PHYSICAL DIAGNOSIS 

scarcely palpable to the immense leukemic spleen which may 
occupy the major portion of the abdominal cavity. Hyrtl en- 
countered at autopsy an enlarged and indurated spleen which 
filled the abdominal cavity and which had created a pressure per- 
foration of the left iliac bone. 

The consistence of the enlarged spleen varies with the cause of 
the hypertrophy, the volume of the organ, and, with the duration 
of the enlargement. Acute transient hypertrophies of the spleen 
arising during the course of the acute infections are not attended 
by any notable alteration in the consistence of the spleen, and such 
hypertrophies are very frequently not palpable for this reason. 
In the immense hypertrophies of leukemia and splenic anemia, on 
the contrary, the organ is hard and occasionally of almost cartila- 
ginous consistence. The amyloid spleen possesses a ligneous con- 
sistence in its advanced stages. Splenic tumors may present mul- 
tiple hard masses, or a single large protrusion which may yield 
fluctuation. Barbieri has elicited fluctuation in the case of a 
large splenic abscess which was afterward treated surgically. 
Similarly, in the case of hydatid cyst of the spleen fluctuation may 
occasionally be demonstrated, as well as hydatid fremitus upon 
palpatory percussion. 

Tenderness upon palpation of the spleen is as a rule only elic- 
ited upon the exertion of deep pressure, and in this case it is 
rather to be attributed to stretching of the capsule of the organ 
than to irritation of the splenic parenchyma. In perisplenitis at- 
tending acute splenitis or the enlarged spleen of acute splenic 
hyperemia tenderness is most readily elicited. Splenic tumors 
rarely exhibit tenderness with the exception of splenic carcinoma. 
Signorelli's spleen point, to which pain is referred in splenic dis- 
ease is situated immediately below the junction of the fifth left 
costal cartilage and the midclavicular line. 

Splenic enlargements exhibit rather a remarkable range of 
mohility. Like the liver, the spleen exhibits respiratory mobility, 
the enlarged organ descending with each inspiration, only to 
remount during expiration. In the upright attitude splenic en- 
largements occupy a lower position in the abdominal cavity than 
obtains during the dorsal decubitus. Upon assuming the right 
lateral decubitus, an enlarged spleen deviates toward the right 
side of the abdominal cavity and at the same time downward; 
while upon assuming the left lateral decubitus the opposite range 
of mobility is noted. The enlarged spleen is readily mobile upon 
manual manipulation. 



EXAMINATION OF THE SPLEEN 577 

A further element in splenic mobility consists in relaxation of 
the splenic ligaments, particularly in the case of multiparas, 
whereby even in the case of a spleen of normal dimensions a con- 
dition of ''floating spleen" is frequently created. Under these 
circumstances the organ may be encountered in the pelvis and 
Morgagni and Ruysch once found the viscus displaced into an in- 
guinal hernia. The displaced spleen is ordinarily recognized by 
the palpable hilum of the organ, in which position the pulsations 
of the splenic vessels are occasionally detected. Moreover, the 
area of splenic dullness between the ninth and eleventh left ribs 
is replaced by intestinal tympany, only to be restored upon the 
manual reposition of the organ. A movable spleen may occupy a 
position superjacent to the abdominal aorta and have the pulsa- 
tions of this vessel communicated to it in the form of a systolic 
rise and diastolic fall of the tumor. Placing the patient in the 
genupectoral posture causes the spleen to fall away from the 
vessel with the consequent suppression of the pseudopulsation. 

The surface of the enlarged spleen may be smooth and uniform, 
or it may be irregular and embossed. The acutely hypertrophied 
spleen and the spleen of the earlier stages of chronic passive con- 
gestion present a smooth and uniform surface ; while the spleen 
which is the site of infarction, abscess, echinococcus cyst, gummata, 
or of carcinomatous infiltration presents an irregular surface with 
nodules or bosses which may or not be umbilicated. 

Friction fremitus is occasionally appreciated upon palpation 
of the abdomen over the spleen which is the seat of perisplenitis. 
This alteration of the splenic surface is much mor,e frequently 
translated in the form of an audible friction sound, however, than 
it is demonstrable as a friction fremitus. Occasionally in the case 
of hydatid disease of the spleen one can elicit hydatid fremitus 
over the organ ; but this sign is not present in the case of hydatid 
cyst of the spleen with the same frequency with which it is en- 
countered over the lung or the liver. 

Theoretically the systolic pulsation of the liver attending ad- 
vanced tricuspid regurgitation should be appreciable over the 
spleen; but clinically it is the exception to encounter such a 
systolic pulsation. Pryor and Drasche have, however, described 
pulsations of the spleen in subjects suffering with aortic insuffi- 
ciency. 

Aside from the floating or wandering spleen which develops as 
a result of relaxation of the suspensory ligaments of the organ, 
the spleen may be displaced in a vertical direction by alterations 



578 PHYSICAL DIAGNOSIS 

in the proportions existing between the pressures which are ex- 
erted upon the superior and inferior surfaces of the diaphragm 
in the presence of diseases of the thoracic and the abdominal 
viscera. 

Downward displacement of the spleen may be caused by in- 
creased intrathoracic tension from hypertrophic emphysema, left- 
sided pneumothorax or pleural effusion, massive pneumonia of the 
left lung, an extensive pericardial effusion, or a thoracic neoplasm. 
The spleen also occupies a lower position than normal in Glenard's 
disease. 

Upward displacement of the spleen occurs when it is pressed 
upon by ascites, tympanites, or large abdominal tumor. Fibroid 
retraction of the left lung or paralysis of the diaphragm will 
likewise cause it to occupy a higher level in the abdominal cavity 
than is normal. 

Percussion. — The inherent difficulties attending delimitation of 
the splenic dullness by percussion cannot be too strongly em- 
phasized. In delimiting the organ, the student will employ 
auscultatory percussion to better advantage than simple plexi- 
metric percussion. Owing to the anatomical situation of the 
spleen between the inferior border of the left lung, the fundus of 
the stomach, and the summit of the left kidney, in percussion of 
the spleen two angles of gastric and colonic tympany are en- 
countered. The first of these angles is encountered at the level 
of the ninth rib in the posterior axillary line, corresponding to 
the course of the superior and anterior borders of the spleen, the 
splenopidmonary angle, which is occupied by the stomach and the 
colon and which yields frank tympany upon percussion when these 
viscera are not filled with solid material. Similarly, the inferior 
border of the spleen meets the external convex border of the left 
kidney at the level of the eleventh rib just external to the left 
scapular line, forming in this situation the splenorenal angle, 
which is occupied by the descending colon, yielding a tympanitic 
percussion sound upon percussion when this portion of the in- 
testine does not contain solid material. 

The presence of these tympanitic areas are of service in the 
delimitation of the spleen when they yield frank tympany; but 
not infrequently the stomach and intestine contain solid material 
and the angles yield a dull note which is suggestive of an aug- 
mentation of the volume of the spleen. Recognizing this possible 
source of error, Piorry always preceded percussion of the splenic 
region by thorough evacuation of the lower intestinal canal. 



EXAMINATION OF THE SPLEEN 579 

Owing to the intimate and continuous relation of the inferior 
border of the spleen with the superior pole of the left kidney in- 
ternal to the left scapular line, it is impossible to establish by 
percussion the inferior limit of the spleen upon the posterior 
surface of the thorax. The superior limit of the organ is estab- 
lished by determining the inferior limit of pulmonary resonance 
in the scapular, postaxillary, and midaxillary lines ; but here 
again, in the presence of effusion into the left pleural sac or in 
the presence of consolidation of the inferior lobe of the left lung 
it becomes impossible to establish the superior limit of splenic 
dullness and hypertrophy of the organ is apt to be suspected when 
it does not exist. A further source of error in splenic percussion 
is added when an enlargement of the liver causes the left extrem- 



^ 



Fig. 242. — Indicating the region for dullness from enlarged spleen. (From Crossen.) 

ity of the latter organ to invade the left hypochondriac region 
and to impinge against the spleen. In this event a false spleno- 
hepatic angle of tympany is established at the summit of Traube's 
semilunar space. 

Percussion of the spleen has been practiced in all possible 
bodily attitudes in the hands of different clinicians. The subject 
has been placed in the abdominal position while the spleen was 
delimited upon the posterolateral aspect of the abdomen; he has 
been placed in the right lateral posture, which frequently causes 
the left iliac crest to impinge against the lower costal arch with 
obliteration of the left flank, which is a productive source of 
error; he has been placed in the right-lateral decubitus of Schus- 
ter; and Zeimssen has preferred to outline the spleen with the 



580 PHYSICAL DIAGNOSIS 

patient in the sitting posture. In the majority of cases the latter 
position is the preferable one during delimitation of the spleen 
by percussion. The right lateral decubitus may be employed if 
a pillow is slipped under the right side of the patient to prevent 
the left iliac crest from impinging against the left costal arch 
and thus disturbing the anatomical relations of the spleen. 

In practicing auscultatory percussion of the spleen with the 
patient in the upright or sitting posture the examiner should apply 
the bell of the stethoscope in the tenth intercostal space in the 
scapular line ; and, after fixing in his mind the quality and pitch 
of the percussion note in the neighborhood of the instrument, he 
should percuss upward toward the inferior border of the lung 
in lines radiating toward the vertebral column, upward in the 















- ------a-^l 


1 




n 


■B'' 








► 




,>JI 




m-^ 


"ft* t 





Fig. 243. — Splenic enlargement in leukemia. 

scapular line, and outward toward the posterior axillary line. 
Having fixed the inferior limits of pulmonary resonance in these 
lines, he should percuss downward in the same lines, whereupon 
he will find that the splenic dullness is continuous with the renal 
dullness to the iliac crest. External to the scapular line, however, 
upon percussing downward the examiner will find that at the in- 
ferior border of the eleventh rib the splenic dullness will give 
place to a tympanitic note in the posterior axillary, midaxillary, 
and anterior axillary lines, if the anterior extremity of the spleen 
reaches the last mentioned line. In delimiting the anterior ex- 
tremity of the organ the examiner percusses from a region of 
frank splenic dullness near the bell of the stethoscope, in a direc- 
tion radiating horizontally forward toward the median line of the 



EXAMINATION OF THE SPLEEN 581 

abdomen. As a rule, when the costoarticular line is reached, the 
dullness of the spleen will give place to gastric tympany in 
Traube's semilunar space. It is very rare for the anterior ex- 
tremity of the normal spleen to surpass this line. Leichtenstern 
has objected to the employment of the costoarticular line in form- 
ing conclusions as to hypertrophy and displacement of the spleen, 
for the reason that the course of this line depends entirely upon 
the conformation of the thorax, with which the spleen has no 
direct connection. This author points out that in a subject with 
an elongated thorax it is quite possible for the anterior extremity 
of the spleen to surpass this line in the absence of hypertrophy 
of the organ; Avhereas in the case of deep chested subjects the 
anterior extremity of the hypertrophied organ may fall short 
of this line. 

Percussion of the splenic region should be practiced during 
tranquil respiration as deep inspiration is capable of modifying 
the superior limit of splenic dullness markedly and the superior 
diminution in the area is not attended by a corresponding in- 
crease in the inferior limits of the dullness. This discrepancy 
occurs through the fact that the respiratory mobility of the spleen 
is limited on account of the relatively small extent of the organ 
which is apposed to the inferior diaphragmatic surface as com- 
pared to that of the liver; and while the inferior border of the 
lung descends into the complementary sinus of the pleura to the 
extent of one to one and one-half inches during full inspiration, 
the spleen is not displaced downward to a corresponding degree. 
Indeed, Grerhardt established the facts that while during full 
inspiration the inferior border of the left lung descended to the 
extent of three to four centimeters, the inspiratory displacement 
of the inferior splenic border did not exceed one centimeter. 

In the pathologic state the examiner may encounter an increase 
in the area of splenic dullness, a decrease in the extent of this 
area, or a total absence of splenic dullness upon percussion. 

The moderate hypertrophies of the spleen which accompany 
the acute infectious diseases are scarcely to be detected during 
percussion of the organ. But in the presence of extensive chronic 
hypertrophy of the organ the area may embrace a large portion 
of the abdominal surface. In more moderate enlargements of the 
spleen there is a coincident extension of the superior and inferior 
limits of the organ with extension of the anterior extremity of 
the organ toAvard the median line of the body. Thus, it not in- 
frequently happens that the anterior extremity of the spleen 



582 PHYSICAL DIAGNOSIS 

comes into contact with the left lobe of tlie liver, with the produc- 
tion of a continuous band of dullness in the hypochondriac and 
epigastric regions, with the formation of a splenohepatic angle of 
gastric tympany at the summit of Traube's semilunar space. Aus- 
cultatory percussion is serviceable in separating enlargements of 
the spleen from growths springing from other abdominal organs ; 
and examination of the blood frequently reveals corroborative find- 
ings. 

Attention has been called in a previous paragraph to the in- 
herent difficulties of delimitation of enlargements of the spleen by 
percussion and the possibility of effusions into the left pleural sac 
and the presence of solid accumulations in the stomach and the 
colon simulating extensions in the various limits of splenic dullness. 

Diminution of the area of splenic dullness is encountered with 
the maximum frequency in connection with hypertrophic emphy- 
sema, when the voluminous lungs encroach upon the superior limits 
of the area of splenic dullness. Similarly, in the presence of tym- 
panites the spleen is crowded into the left vault of the diaphragm 
and the area of splenic dullness is greatly restricted or abolished. 
In the aged subject the spleen frequently undergoes a striking 
diminution in size, with consequent restriction of the area of splenic 
dullness. 

Absence of splenic dullness is noted in the case of the wandering 
spleen, in which the spleen has fallen from its normal habitat, and 
in the rarer cases of congenital absence of the organ. In the pres- 
ence of pneumoperitoneum the collection of gas may insinuate 
itself between the spleen and the abdominal wall and temporarily 
abolish the dullness of the spleen. 

Before basing conclusions as to the probable dimensions of the 
spleen upon the percussion findings, the student should pass in re- 
view the various factors which may influence these findings, and 
which have been enumerated in the foregoing paragraphs; and a 
diagnosis of splenic hypertrophy should not be formulated in any 
case in which the spleen does not become palpable. 

Auscultation. — In the presence of perisplenitis a peritoneal fric- 
tion sound is occasionally audible synchronous with the respiratory 
movements or provoked by pressure with the stethoscope. This 
friction sound is much more readily detected upon auscultation 
than is the accompanying fremitus upon palpation of the splenic 
region. 

Occasionally during the course of splenic enlargements attend- 
ing leukemia, in the presence of hepatic cirrhosis, and in the case 



EXAMINATION OF THE KIDNEYS 583 

of a floating spleen, vascular murmurs are detected upon ausculta- 
tion of the splenic area. The significance of these vascular bruits 
have been variously interpreted by different observers and their 
precise mode of generation is still a subject of controversy. Ger- 
hardt detected a double murmur over a pulsatile spleen in a sub- 
ject of aortic insufficiency in connection with the double murmur 
of Duroziez over the femoral artery. Griesinger holds that vascu- 
lar murmurs encountered over a hypertrophied spleen are due to 
the flow of blood through the large venous trunks ; Tersti holds that 
they are due to twisting and relaxation of the afferent and efferent 
splenic vessels ; Mosler attributes them to contractions of the splenic 
arteries; and Piazza believes that in the case of the indurated 
spleen they are due to constriction of the splenic arteries, while in 
the case of the soft spleen they are due to dilatation of the same 
vessels. 

EXAMINATION OF THE KIDNEYS 

Clinical Anatomy. — The kidneys are solid organs situated in 
the posterior portion of the abdomen, behind the peritoneum, upon 
either side of the vertebral column. The superior extremities of 
the kidneys correspond to the level of the upper border of the 
twelfth dorsal vertebra ; w^hile the inferior extremities are on a 
level with the third lumbar vertebra. Owing to its relation with 
the right lobe of the liver, the right kidney occupies a slightly 
lower level in the abdominal cavity than does the left kidney. 

The normal adult kidney is approximately four and one-half 
inches in length, two and one-half inches in width, and two inches 
in thickness. The left kidney is slightly longer and narrower 
than is the right kidney. In the infant and the young child the 
kidneys are relatively larger than in the adult subject. The 
relative weight of the kidney in the adult to the entire body 
weight is 1:240, whereas in the infant the proportion is 1:120. 

Posteriorly the kidneys rest upon the muscles of the posterior 
abdominal wall, the psoas, the quadratus lumborum, the fascia 
of the transversalis, and the diaphragm. The anterior surface of 
the right kidney is in relation with the inferior aspect of the 
liver, the descending portion of the duodenum and the hepatic 
flexure of the colon and the adrenal. The large intestine is united 
to the anterior face of the kidney by areolar tissue, with the 
result that in the presence of enlargement of the kidney from 
neoplasm or other cause the large intestine is carried before the 
kidney in its hypertrophy. The anterior surface of the left 



584 PHYSICAL DIAGNOSIS 

kidney is in relation with the posterior' Surface of the stomach, 
the spleen, the body of the pancreas, the jejunum, the adrenal 
and the splenic flexure of the colon. While the large intestine 
passes across the ventral face of the left kidney, it is not moored 
securely to the kidney, with the result that during hypertrophy 
of the kidney the colon is occasionally but not invariably carried 
in front of the organ during the renal hypertrophy. 



Fig. 244. — Surface markings of kidneys, ureters and abdominal vessels. Anterior view. 

(From Eisendrath.) 
I, inferior vena cava; 3, aorta — celiac axis just below 2; j and 4, right and left renal 
veins; 5 and 6, right and left renal arteries; 7 and S, righi and left ureters; 9, left 
spermatic vein; 10, right spermatic vein; //, superior mesenteric artery; 12 and it,, right 
and left spermatic arteries; 14, external iliac arteries; 15, external iliac veins; RK, right 
kidney; LK, left kidney; SP, spleen. 



EXAMINATION OF THE KIDNEYS 



585 



The kidneys occupy portions of the epigastric, umbilical, hypo- 
chondriac, and lumbar regions upon either side of the median 
line. The superior pole extends as high in the epigastric region 
as a transverse line drawn about two inches below the ensiform 
process. The inferior pole extends below the subcostal line, only 
slightly in the case of the left kidney, and to a greater degree in 
the case of the right kidney. In the female subject the kidneys 
occupy a lower position in the abdominal cavity than in the male 
subject. In both sexes the superior pole of the organ is nearer 
the median line of the body than is the inferior pole. 




Fig. 245-^4. — Topographic anatomy of 
neys and ureters. 



kid- 



Fig. 245-5. — Topographic anatomy of kid- 
neys and ureters. 



The kidney is roughly reniform in shape, presenting a convex 
external border which conforms anatomically to the outer border 
of the quadratus lumborum muscle, and presenting a concave 
internal border, which bears in its midportion a deep fissure, the 
hilum of the kidney, for the entrance and exit of the renal vessels, 
nerves, lymphatics, and the ureters. 

The kidney is maintained in position by a surrounding bed of 
adipose tissue, the perirenal fat, and by a sheath of fibrous tissue, 



586 PHYSICAL DIAGNOSIS 

which is continuous in the median line of the abdominal cavity 
and which is anchored superiorly with the fascia of the dia- 
phragm. 

Congenital absence of one kidney has been observed, and not in- 
frequently one kidney is considerably larger than its fellow of 
the opposite side. Occasionally also the kidneys are fused at 
their inferior poles with the production of a '^horseshoe kid- 
ney." In other instances the fusion of the organs is complete, 
the kidneys being represented by a single large organ with two 
ureters. 

Physical Examination. — During physical examination of the 
kidneys inspection and palpation are the principal methods em- 
ployed, the latter mode of examination in the majority of cases 
yielding much more definite and precise data than the former. 
In certain cases an attempt should be made to outline the kidneys 
by percussion, the technic and the difficulties of which are de- 
tailed in a subsequent paragraph. Auscultation is scarcely ever 
resorted to in the examination of the kidneys. 

Inspection. — The normal kidney, occupying its normal situation, 
yields no evidence of its existence upon inspection of the abdomen. 
It is only in the presence of hypertrophy of the organ as a result 
of the development of renal neoplasms, extensive hydronephrosis, 
in the case of the large cystic kidney, or in the case of the displaced 
kidney that inspection of the abdomen reveals any abnormality 
in contour which is of localizing value. 

A progressive enlargement of the kidney, whether it be due to 
neoplasm or other cause, produces moderate bulging of the abdom- 
inal wall in the first place limited to the lumbar regions of the 
abdomen, between the lower border of the costal arch and the iliac 
crest. In the further evolution of the hypertrophy the bulging 
progressively involves the umbilical region, producing ventral pro- 
trusion of the abdominal wall in this locality; and in the further 
growth of the organ, the liver or the spleen is crowded upward with 
the production of a variable degree of flaring of the costal arch 
upon the side of the enlarged kidney. Under these circumstances 
a renal enlargement is distinguished from a hypertrophy of the 
liver or of the spleen by the absence of respiratory excursions in 
the case of renal growths. In testing for respiratory excursion of 
the tumor, however, considerable care must be exercised in order 
to avoid confounding the movement of the abdominal wall over the 
surface of the growth for a true respiratory movement of the renal 



EXAMINATION OF THE KIDNEYS 587 

enlarg'ement, and it may be necessary to employ palpation in 
order to differentiate the two movements. 

In the presence of extensive hypertrojohy of the rigiit or the 
left kidney, associated with bnlging of the abdominal wall, there is 
occasionally observed a ridge traversing the prominent area of the 
abdominal wall, which corresponds to the conrse of the ascending 
colon in the case of the rigiit kidney and to the course of the de- 
scending colon in the case of an enlargement of the left kidney. 
As the ascending colon is moored to the anterior surface of the 
right kidney by areolar tissue, when the kidney enlarges the colon 
is carried forward in front of the growth ; and if the intestine 
contains gas, an elevation corresponding to the course of the ascend- 
ing colon is produced upon the anterior abdominal wall. In the 
case of the right kidney this elevation pursues a course from below 
upward and toward the left side of the abdomen. In the case of 
enlargements of the left kidney this sign is frequently lacking, as 
the descending colon possesses no definite connection with the left 
kidney and frequently the kidney passes forward to meet the ante- 
rior abdominal wall within the limits of the descending colon. 

The development of a perinephritic abscess in the perirenal 
tissues produces local bulging upon the posterior surface of the 
abdomen in the costovertebral angle occuj^ying the interval be- 
tween the twelfth rib and the vertebral column. When rupture of 
the abscess becomes imminent there is a circumscribed elevation of 
edematous or discolored integument at the site of imminent rupture. 
When these signs are in evidence, the examiner should practice 
very careful palpation of the vertebra in the attempt to exclude a 
possible confusion with an abscess, the result of vertebral caries. 

A displaced kidney is occasionally capable of producing a cir- 
cumscribed prominence of the anterior abdominal wall, which may 
be situated low down in the abdominal cavity and may simulate a 
tumor of the ovary or other pelvic or abdominal organ. Bartels 
encountered a displaced kidney at the level of the right iliac fossa 
in a multipara with thin abdominal walls in which case it was 
possible to recognize the kidney by its characteristic reniform 
shape. 

Palpation. — In the practice of palpation of the kidney the 
patient assumes the dorsal decubitus with the knees drawn up 
and supported, and the arms lying loosely at the sides. 

The examiner sits upon the side of the kidney to be palpated 
and bimanual palpation is employed. The examiner exerts pres- 
sure with the index and middle fins^ers of the left hand in the 



588 PHYSICAL DIAGNOSIS 

costovertebral angle, the interval just below the twelfth rib ad- 
jacent to the vertebral column. The examiner at the same time 
places his right hand upon the anterior abdominal wall one inch 
external to the linea semilunaris, his fingers directed upward 
just below the costal arch. As the patient inspires deeply the 
examiner makes downward pressure with the finger-tips of the 
right hand, at the same time exerting pressure with the left hand 
in the costovertebral angle. If during this maneuver the in- 
ferior pole of the kidney be felt at the completion of inspiration, 
but glides back into place during expiration, the condition consti- 
tutes movable kidney. 







... 


1 



Fig. 246. — Palpation of the kidney. 

Three degrees of movable kidney are recognized. In the first 
degree, only the inferior pole of the kidney is palpable; in the 
second degree the inferior half of the kidney is palpable; while 
in the third degree of movable kidney the entire anterior face of 
the organ is palpable. 

If, on the contrary, the kidney fails to glide back into its 
normal position during expiration, if during this period the entire 
kidney remains palpable and can be pushed about in the abdom- 
inal cavity, the condition is termed displaced kidney, or floating 
kidney. The right kidney is frequently movable in girls and 



EXAMINATION OF THE KIDNEYS 



589 



women, particularly in subjects with moderate enteroptosis ; with 
less frequency is the kidney movable in the male subject. 

The normal kidney occupying its normal situation in the abdom- 
inal cavity is always palpated with difficulty and frequently is not 
palpable. But a movable kidney, a displaced kidney, and the 
kidney which is enlarged as a result of hydronephrosis, neoplasm, 
pyelonephrosis or surgical kidney is readily palpable and occasion- 
ally yields fluctuation under proper conditions. 

When upon palpation of the kidneys the examiner encounters an 
abnormality in the dimensions or contour of the kidneys, he should 




Fig. 247. — Indicating the rcgiun fur kidney tenderness in front, on the right side. 

(From Crossen.) 



proceed to make a detailed study of the sensibility, the form, and 
the volume of the kidney, its limits in respect to the adjacent ab- 
dominal viscera, its range of mobility, the state of its surface, and 
its consistence. 

The sensibility of the kidney is variable both in the normal sub- 
ject and in pathologic states of the organ. The subjective sensa- 
tion which is experienced upon compression of the normal organ is 
dull and aching, somewhat analogous to the sensation which is 
experienced upon moderate compression of the testicle. In the 
presence of pathologic changes in the organ the sensibility ranges 
from this dull pain to very lively, excruciating pain. Frerichs 



590 



PHYSICAL DIAGNOSIS 



calls attention to the fact that the left kJdney is normally more 
sensitive to pressure than is the right kidney, probably as a result 
of its more superficial position, with the result that a greater degree 
of pressure is exerted upon this kidney during the routine palpa- 
tion of the kidneys. In renal disease tenderness may be elicited 




Fig. 248. — The point for kidney tenderness laterally. (From Crossen.) 




Fig. 249. — The point for kidney tenderness posteriorly, (From Crossen.) 



EXAMINATION OF THE KIDNEYS 



591 



upon pressure with the finger-tips upon the anterior abdominal 
wall two inches below the costal arch and slightly external to the 
mid-Poupart line. Upon the lateral wall of the abdomen tender- 
ness is elicited upon pressure exerted at the same level. Posteriorly 
renal tenderness is elicited upon exerting pressure in the costo- 
vertebral angle. 

The form of the kidney, even in pronounced enlargements of the 
organ is usually maintained to such a degree that the organ may be 
recognized by its reniform contour. Frequently it is considerably 




Fig. 250. — The area for left kidney tenderness in front. (From Crossen.) 

elongated ; and in the case of the polycystic kidney is studded with 
regularly spherical nodules. 

The volume of the kidney in the presence of pathologic changes 
of the organ presents all gradations from the very moderate en- 
largement of the gland which scarcely renders it palpable to im- 
mense hypertrophy which fills a considerable portion of the ab- 
dominal cavity. 

The examiner not infrequently encounters difHculty in the case 
of the pathologic kidney in establishing its limits in respect to the 



592 



PHYSICAL DIAGNOSIS 



neighboring abdominal organs. The inflamed kidney or the kidney 
which is the seat of malignant disease is very prone to contract 
adhesions with adjacent viscera, particularly with the liver and 
with the spleen. Occasionally it is possible to palpate the hilum of 
the organ and to appreciate the pulsation of the renal vessels in 
this situation. 

The range of mobility of renal enlargements is readily studied 
in the case of moderate hypertrophies of the organ, and with con- 
siderable difficulty in the case of excessive enlargement of the 
kidnej^ In the moderately hypertrophied kidney it is readily de- 




Fig. 251. — ^Method of palpating for a mass in the kidney region. The structures are 
caught between the hand behind and the one in front. (From Crossen.) 

termined upon bimanual palpation that its range of mobility is 
backward into the loin, while it possesses very little or no lateral 
mobility. This radius of mobility of the kidney is of considerable 
aid in differentiating renal enlargements from a distended gall 
bladder, which presents a distinct lateral mobility. Similarly, the 
kidney possesses no true respiratory mobility in contradistinction 
from hepatic growths which possess this mobility to a striking 
degee. 

The state of the surface of the diseased kidney is variable. Renal 
hypertrophies with smooth surfaces point to hydronephrosis and 



EXAMINATION OF THE KIDNEYS 



593 



cystic disease of the organ; while those with irregular, nodular 
surfaces point to solid tumors of the organ, notably to carcinoma 
and sarcoma, and to the polycystic kidney. In cases of renal hyper- 
trophy in which the colon is carried forward in front of the organ 
and is compressed between its anterior face and the abdominal 
wairthe intestine is occasionally palpable in the form of a rounded 
band crossing the anterior surface of the kidney. 

The consistence of the kidney in the presence of renal hyper- 
trophy is frequently of considerable aid in the determination of 
the nature of the underlying lesion. In the case of solid tumors 
of the organ the tumor is hard and unyielding upon palpation. In 




Fig. 252. — Point for kidney tenderness laterally. (From Crossen.) 



the case of hydronephrosis, on the contrary, the organ is soft and 
yielding, and fluctuation is occasionally to be detected. Fluctua- 
tion is elicited most readily when the walls of the organ are not 
unduly tense ; and an increase in the quantity of the fluid and of 
the tension of the walls renders the fluctuation less distinct. In the 
presence of echinococcus disease of the kidney it is occasionally 
possible to elicit hydatid fremitus over the site of the cyst. 

Occasionally the examiner may be confused by a solid mass which 
crosses the median line low down in the abdominal cavity and 
which is continuous with the inferior poles of the kidneys. In this 
connection he should think of the possibility of the existence of the 



594 



PHYSICAL DIAGNOSIS 



congenital fusion of the inferior poles of tl^ organ with the produc- 
tion of the ''horseshoe kidney," which may be situated as low as 
the concavity of the sacrum. 

Occasionally a horseshoe deformity of the kidneys has imparted 
to it the systolic pulsations of the subjacent aorta, simulating with 
its rise and fall an aneurysm of this vessel. 

Moreover, upon palpation of the renal region, the examiner may 
encounter a sensation of diffuse resistence to the palpating hand 
rather than a distinct tumor. In this event he should think of the 
possibility of purulent infiltration of the perirenal tissues or peri- 




Fig. 253. — Points for kidney tenderness in the back. (From Crossen.) 

nephritic abscess and should carefully palpate the costovertebral 
angle and endeavor to elicit fluctuation if such be demonstrable. 
Also when a distinct growth is palpated in the renal region 
doubt may arise as to whether or not the growth is of renal origin 
or whether it is an enlarged gall bladder, or whether it springs 
from the liver, spleen, pancreas, or the pylorus. In this connection 
the examiner should recall that a tumor of the kidney is situated 
more laterally than is a distended gall bladder, and exhibits its 
principal radius of mobility backward into the loin, while that 
of the gall bladder is manifested transversely below the inferior 
margin of the liver. Also, as stated in a previous paragraph, the 
ascending colon is attached by areolar tissue to the inferior pole 



EXAMINATION OF THE KIDNEYS 595 

of the right kidney so that a renal hypertrophy carries the tympan- 
itic colon before it, while tnmors of the gall bladder, pylorus, or 
pancreas reach the abdominal wall nearer the median line, without 
the intervention of the tympanitic colon. 

In the case of the left kidney, however, owing to the fact that 
there is no anatomic attachment of the kidney to the descending 
colon, the colon is frequently displaced, allowing the renal tumor 
to come forward and meet the abdominal wall. However, in these 
circumstances, the displaced colon will yield a tympanitic note 
along the border of the solid mass. Tumors of the spleen reach the 
abdominal wall above the transverse colon, which is displaced 
downward. 

Hepatic enlargements exhibit distinct respiratory mobility, which 
is absent in the case of renal tumors ; hepatic enlargements develop 
above the transverse colon, which they displace downward ; and, as 
Bright showed, in the case of renal enlargements it is possible to 
insinuate the palpating hand between the growth and the anterior 
abdominal wall, while in the case of hepatic growths this maneuver 
is impossible. 

Percussion. — In the physical examination of the kidneys, percus- 
sion is inferior to palpation as a method of examination, and its 
employment with satisfactory results is practically confined to the 
study of enlargements of the organs. In the case of the normal 
kidney it is impossible to map out any area of renal dullness upon 
the anterior surface of the abdomen, and it is exceedingly difficult 
in the case of the normal organs to establish any area of renal dull- 
ness upon the posterior abdominal wall which bears any definite 
anatomic relation to the true position of the kidneys. In the case 
of the normal kidneys, the superior limits of the organs are always 
obscured by their relations with the liver and with the spleen. It 
is equally impossible to delimit by percussion the internal concave 
borders of the organs on account of the thick musculature occupy- 
ing the areas upon either side of the vertebral column and because 
of the fact that the transverse processes of the vertebrge frequently 
intervene between the internal borders of the organs and the poste- 
rior abdominal wall. 

Externally it is possible, when the colon does not contain solid 
fecal accumulations to establish along the external border of the 
thick bed of muscles paralleling the vertebral column a limit where 
the so-called renal dullness gives place to intestinal tympany. This 
limit is commonly accepted as the external limit of renal dullness, 
and is assumed to represent the external border of the normal 



596 PHYSICAL DIAGNOSIS 

kidney; but Weil established the fact tliaf this limit corresponds 
merely to the free edge of the massive muscular column erected 
upon either side of the vertebral column and in no wise represents 
the anatomic position of the external border of the normal kidney. 
For the same anatomic reason the examiner will very rarely succeed 
in delimiting the inferior pole of the kidney, as it is covered by the 
thick superjacent musculature, which effectually deadens any tym- 
panitic sound which might be generated in the intestine at the 
level of the inferior pole of the kidney. Thus, percussion of the 
kidney is practically limited to the delimitation of renal enlarge- 
ments, in which the hypertrophied organ approaches the anterior 
abdominal wall, thereby enabling the examiner to base his conclu- 
sions upon certain regional variations in the percussion sounds 
elicited upon this abdominal surface. 

Here renal growths are differentiated from hepatic hypertro- 
phies by the absence of respiratory mobility, by the fact of their 
carrying the tympanitic colon in advance of them, and by the 
impossibility in the case of hepatic growths of insinuating the 
finger-tips between the growth and the ventral abdominal wall. 

Similarly, growths springing from the spleen exhibit respiratory 
mobility ; they are situated higher up in the left hypochondriac 
region than are renal growths ; while the finding of the colon in 
front of the growth pleads in favor of a renal growth, as growths 
of the spleen develop above the level of the colon, which they dis- 
place downward. 

Renal growths of extensive dimensions may be mistaken for 
growths of the ovary. In this connection the examiner should re- 
call that renal growths develop from above downward, while tumors 
of the ovary develop from below upward; that renal tumors are 
ordinarily encountered behind the intestines and carry the tympan- 
itic colon forward before them, while ovarian tumors are situated 
in front of the intestine; and that renal tumors are attended by 
urinary changes, while ovarian growths provoke menstrual dis- 
turbances and uterine displacements. 

Auscultation. — Auscultation is scarcely employed in the exami- 
nation of the kidneys. Bristone and Ballard have encountered 
vascular murmurs over the kidney in the presence of renal car- 
cinoma, which simulated aneurysm of the abdominal aorta. 

EXAMINATION OF THE BLADDER 

The bladder is a hollow viscus, lying posterior to the symphy- 
sis pubis. A pelvic organ in the adult subject, in the infant the 



EXAMINATION OF THE URETERS 



597 



bladder is situated in the abdominal cavity above the symphysis 
pubis. 

Physical Examination. — Inspection. — The normal bladder causes 
no visible prominence of the abdominal surface; but when dis- 
tended it produces bulging; in the hypogastric region which, in 
extreme cases, may extend into the umbilical region. The cause 
of such distention may be prostatic hypertrophy, a lumbar cord 
lesion, or the comatose state of an acute infection. 

Palpation. — The moderately distended bladder cannot be pal- 
pated through the abdominal wall ; when, however, distended fully, 
it may be felt as a tense spherical mass in the hypogastric region. 

Percussion. — Percussion is only available in cases of extreme 
distention of the bladder, when a flat note is elicited over the dis- 
tended bladder in the hypogastric and umbilical regions, sur- 
rounded by a zone of intestinal tympany. 

Auscultation is not emploj^ed in the physical examination of the 
l)ladder. 




Fig. 254. — Indicating the site to search 
for tenderness of the right ureter. This 
may be found anvwhere from the nonit 
indicated to some distance inside the circle, 
towards the umbilicus. (From Crossen.j 



Fig. 255. — Palpating for tenderness or 
thickening about the right ureter. (From 
Crossen.) 



EXAMINATION OF THE URETERS 

The ureter is a cylindrical membranous tube, approximately 
from ten to twelve inches in length and one-sixth inch in diameter, 



598 PHYSICAL DIAGNOSIS 

which takes origin from the pelvis of the kidney, and which 
terminates in the walls of the urinary bladder. The ureter pur- 
sues an oblique course downward and inward through the abdom- 
inal cavity to cross the brim of the pelvis and enter the walls of 
the bladder. 

The course of the ureter is indicated upon the surface of the 
abdomen by a line drawn almost vertically from a point in the 
umbilical region approximately two inches external to the median 
line of the body, at the level of the anterior extremity of the 
twelfth rib, to a point a little below the umbilicus, whence the 
course of the tubes converges toward the median line as the 
symphysis pubis is approached. 

Physical Examination. — The normal ureter cannot be palpated, 
and an enlarged ureter is palpable only in the emaciated subject 
with very lax abdominal walls. However palpation of the um- 
bilical region over the course of the ureter may elicit tenderness 
due to inflammation of the tube which upon the right side of the 
abdomen should not be mistaken for inflammatory disease of the 
vermiform appendix. 



PART III. THE HEAD, NECK AND EXTREMITIES 



SECTION I 
THE HEAD AND NECK 



CHAPTER XXVI 

EXAMINATION OF THE HEAD 

In the examination of the head the following points should be 
noted by the examiner: 

1. Size and shape. 

2. Condition of the fontanelles 

and sutures (in children). 

3. Condition of the bones. 

4. Condition of the hair. 

5. Position of the head. 

6. Movements of the head. 

Size and Shape. — The head may be abnormally small (micro- 
cephalia) with premature closure of the fontanelles and sutures, 
a condition usually associated with idiocy. 

A very large head is encountered in hydrocephalus, wdiile mod- 
erate enlargement occurs in connection with rickets, cretinism 
and hypertrophia cerebri. 

In rickets the circumference of the head is increased two or three 
inches, the enlargement being chiefly due to thickening of the 
cranial bones. The shape of the head is rather square (box head), 
owing to the presence of osteoid bosses upon the frontal and 
parietal regions. The rachitic head is flattened at the vertex and 
over the occiput. Soft, compressible areas, craneotahes, are often 
present ; the fontanelles are widely open and the sutures are tardy 
in closing. 

Concomitant signs of rickets are the rosary, the chicken or pigeon 
breast, spinal curvature, tumid belly, and changes in the extremi- 
ties of the long bones. 

599 



600 PHYSICAL DIAGNOSIS 

Hydrocephalic Head. — In hydrocephalics the head is enlarged, 
the circumference sometimes reaching 32 inches at the eighth 
month of life. The large prominent forehead is in marked con- 
trast with the small face. The fontanelles and sutures are widely 
open, and the veins of the scalp are prominent and distended. 
The skull is very thin and may be translucent to candle light. 
The child has difficulty in holding the head up. 

While the head in hydrocephalus somewhat resembles the ra- 
chitic head, there are differences. In hydrocephalus the shape is 
globular rather than square as in rickets ; also in hydrocephalus 
the sutures and fontanelles are wider and the fontanelles bulge, 
which is not true of rickets. 

In cretinism the head is large, flattened at the vertex, with open 
sutures and fontanelles, but without bulging. The facial expression 
is dull, the nose flat, and the face large, with puffy eyelids. The 
extremities are short and thick; and the tongue is large, often 
protruding from the mouth. There are pads of fat in the supra- 
clavicular regions. 

Fontanelles and Sutures.— The posterior fontanelle normally 
closes about the end of the second month, while the anterior fon- 
tanelle closes between the eighteenth and twentieth months of 
life. 

Tardy closure of the fontanelles occurs most frequently in con- 
nection with rickets. Closure is also delayed in hydrocephalus 
and cretinism. In rickets the fontanelles may remain open beyond 
the fourth year of life. 

Btdging fontanelles indicate increased intracranial pressure, and 
are noted in hydrocephalus, cerebral hemorrhage, meningitis, brain 
tumor, sinus thrombosis, meningeal hemorrhage, and during acute 
fevers. 

Depressed fontanelles are noted during chronic wasting diseases, 
in pulmonary diseases attended by dyspnea, after severe diarrhea, 
during the early stages of meningitis, and in cholera infantum. 

Enlargement of the fontanelles, the anterior fontanelle exceeding 
one inch in diameter, is suggestive of rickets, hydrocephalus, cre- 
tinism, and may be a hereditary condition. 

Open Sutures. — The sutures of the child's head normally close 
between the sixth and eighth months. Open sutures after this 
time are significant of rickets, cretinism, or hydrocephalus. 

Condition of the Bones of the Head. — A number of changes in 
the bones of the head possess diagnostic significance. 



EXAMINATION OF THE HEAD 



601 



Craniotabes, the presence of thin, compressible areas in the 
cranial bones, is symptomatic of rickets, infantile syphilis, or chon- 
drodystrophy. 

Osteoid tosses on the frontal and parietal bones in infants are 
symptomatic of rickets. 

Soft, nodular swellings on the skull, which become harder with 
advancing age, are symptomatic of s^^philitic periostitis of the cra- 
nial bones. 





■ 




PI 


mf^ 


i|^B 


I i 


■1 



Fig. 256. — Alopecia areata. Numerous small patches have coalesced, forming a 
rather unusual picture, inasmuch as the baldness is not as complete as visual. (From 
Hazen.) 



Tenderness over the mastoid process, with fever, deep-seated pain, 
and, if pus has formed, fluctuation, is symptomatic of inflamma- 
tory disease of the mastoid cells. 

The Condition of the "Hsiir.— General falling of the hair fol- 
lows many acute febrile conditions, notably typhoid fever. General 
loss of hair also occurs in gout and myxedema. 

Circumscrihed falling of the hair, producing local areas of bald- 
ness, results from tinea tonsurans, scarring from local trauma, 
neuralgia of the trigeminal nerve, and syphilis. 



602 



PHYSICAL DIAGNOSIS 



In a child baldness in the occipital region, with excessive sweat- 
ing of the head suggests rickets. 

Color of the Hair. — The color of the hair may be altered by local 
application of chemicals, or as a result of metallic poisoning. Thus, 
hydrogen dioxide bleaches the hair, while the hair assumes a green 
color in chronic copper poisoning. 

Canities, whiteness of the hair, a physiologic change in persons 
past middle age, is observed in connection with syphilitic endo- 
arteritis involving the scalp and accompanying trophic nervous dis- 
turbances. 




Fig. 257. — Alopecia areata. A patch that is not as yet completely denuded. (From Hazen.) 



Position of the Head. — Retraction of the head occurs in tetanus, 
strychnine poisoning, and meningitis. In children retraction of the 
head may occur during attacks of acute indigestion, the significance 
of which is slight ; but it should not be mistaken for retraction in 
connection with grave affections. 

Lateral deviation of the head is observed in connection with 
wry-neck due to spasm of the sternomastoid muscle, in rheu- 
matic torticollis, in which there is painful contraction of the sterno- 
mastoid and trapezius, and in hematoma of the sternomastoid, 
which is attended by an oval tumor in the belly of the muscle. In 



EXAMINATION OF THE HEAD 



603 



young children lateral deviation of the head may be due to injury 
to the muscles of the neck during parturition. 

Abnormal fixation of the head is observed in connection with 
retropharyngeal abscess, cervical adenitis, rheumatism, arthritis 
deformans, extensive scars from burns, and in Pott's disease. 

Movements of the Head. — Nodding spasm, a rhythmical up 
and down movement of the head, is observed in patients suffering 
with hysteria, and occasionally in connection with rickets. The 
movement may be continuous ; or may be absent during quiescence 
and only brought out by excitement. 

Arrhythmic, purposeless movements of the head occur in Syden- 
ham's chorea. 




Fig. 258. — Syphilitic alopecia. (From Hazen.) 



Spasmodic movements of the head, in which the head deviates 
laterally, occur in spasmodic torticollis. 

InaMlity to move the head occurs in connection with the flaccid 
paralysis of acute anterior poliomyelitis, in caries of the cervical 
vertebra, and in the late stages of cerebrospinal meningitis, and 
during comatose states from any cause. 

The Ear.— Congenital Defects.— Among the congenital defects 
of the auricle may be mentioned entire absence of this portion of 
the auditory apparatus; excessive development or defective de- 
velopment of the auricle, macrotia and microtia respectively; the 



604 PHYSICAL DIAGNOSIS 

presence of more than one auricle, or pctlyotia; malformation or 
absence of the lobule, helix, or antihelix. 

Fistula auris congenita, a rare defect, consists of a short blind 
canal, lined with epithelium, with its orifice either in front of 
or below the tragus. 

Hematoma auris, or othematoma, is a bluish-red swelling involv- 
ing the concha and fossa of the antihelix and helix, the lobule es- 
caping. It is a trophoneurosis, and the condition is observed most 
commonly among insane patients, in whom it was formerly at- 
tributed to ill-treatment. A similar bluish discoloration, involving 
the entire auricle may follow trauma, due to effusion of blood be- 
neath the perichondrium. 

Tophi, small, hard nodules of sodium urate, are frequently 
found in the helix in gouty patients. 

Cysts of the auricle, small, noninflammatory tumors, contain- 
ing clear fluid, are sometimes encountered about the auricle. They 
are differentiated from perichondritis by the absence of pain and 
other inflammatory signs. 

Sebaceous cysts, due to blocking of the ducts of the sebaceous 
glands and accumulation of the secretion, produce roundish tumors 
situated usually in the skin behind the lobule or in the lobule. 

Blueness of the auricle occurs as a sign of cyanosis, and also in 
the early stages of frostbite, in which it becomes later yellowish- 
white. 

Keloid may be encountered on the lobule, due to piercing the 
lobule for earrings, most commonly in the negro race. 

Otomycosis. — In otomycosis, due to the growth of the Asper- 
gillus Niger in the external auditory canal, the canal is studded 
with black spots, Avhich under the microscope reveal the presence 
of the fungus. 

Discharge of blood from the external auditory meatus is in- 
dicative of fracture of the base of the skull or otitis media. In 
the case of fracture of the base of the skull the blood is mixed with 
cerebrospinal fluid, which prevents coagulation; while in otitis 
media there is admixture with pus. Discharge of pus unmixed 
with blood indicates purulent otitis media or abscess. 



CHAPTER XXVII 

EXAMINATION OF THE FACE 

CONTOUR OF THE FACE 

The contour of the face is altered by many diseases, chief 
among which may be mentioned acromegaly, hydrocephalus, os- 
teitis deformans, leontiasis ossium, leprosy, and facial hemi- 
atrophy and hemihypertrophy. 

Acromegaly. — In acromegaly the face assumes an oval or el- 
liptical shape, due to the enlargement of the frontal and malar 
bones, and the mandible, which become massive. Owing to this 
growth the teeth are separated by intervals, the lower teeth 
projecting beyond those of the upper jaw. The ears are large, 
the nose thickened, and the superciliary ridges are prominent. 
The tongue is large, sometimes protruding from the mouth. The 
eyes are unchanged; and, by contrast with the massive features, 
appear abnormally small. 

Cretinism. — In cretinism the face is broad and flat, presenting 
a bloated appearance. The eyes are wide apart, the eyelids are 
thickened, and the nose is broad and negroid. There is pouting of 
the lips and protruding tongue, the child presenting a picture of 
imbecility. 

Myxedema. — In myxedema the lines of expression in the face 
are obliterated by swelling in the subcutaneous tissue. The con- 
tour of the face has been likened to a "full moon." The nos- 
trils and lips are large and thick, the mouth is enlarged, and 
there is usually a reddish patch over the cheek. Other signs of 
myxedema are the dry rough skin, the increase in bulk of the 
whole body, the inelastic swelling of the subcutaneous tissue, 
which does not pit upon pressure, and local deposits of subcu- 
taneous tissue in the supraclavicular fossas. 

Hydrocephalus. — The face in this disease is triangular with the 
base of the triangle above. The features, which are of normal 
size, present a marked contrast with the enormous forehead. 

Osteitis Deformans. — The face in this disease is triangular 

605 



606 



PHYSICAL DIAGNOSIS 




Fig. 259. — Face of acromegaly. (Butler, after Worchester.) 




Fig. 260. — A case of congenital myxedema. (Woolley, after Kassowitz.) 



EXAMINATION OF THE FACE 



607 




Fig. 2('il. — Face of myxedema. (Butler, after Gordinier.) 




Fig. 262. — ^Leprosy, (From McFarland.) 



608 



PHYSICAL DIAGNOSIS 



with the base directed upward, owing to* the thickening of the 
bones of the cranium. The head is carried in a position of for- 
ward inclination. The disease is associated with bowing of the 
bones of the upper and lower extremities, kyphosis, and not in- 
frequently ankylosis of the spine. 

Leontiasis Ossium.— This disease is characterized by progres- 
sive enlargement of the bones of the cranium and face, beginning 
usually in the superior maxillary bones. Blindness occasionally 
develops from pressure upon the optic nerves. 





-"■)■) 










..••• .,f^-- 


■■^^ 


f 




^. 


'i: 




^' ' 


,f 




^f'-r" " 











Fig. 263. — Facial hemiatrophy. (From Butler.) 



Leprosy. — When the nodes of leprosy develop in the face they 
produce thickening of the skin of the forehead and cheeks. The 
nose is flat and thick; the lips are thick; the ears are thick and 
large, while the eyebrows, eyelashes, and beard are shed, con- 
stituting the Facies Leontina. 

Facial Hemiatrophy. — In facial hemiatrophy one-half of the 
face is smaller than the opposite half, with a sharply defined ver- 
tical line of junction. The condition usually begins during child- 
hood in one or two spots on one side of the face. The skin be- 
gins to undergo atrophic changes, foUoAved by a similar involve- 
ment of the underlying subcutaneous tissue, muscles and bones. 



EXAMINATION OF THE FACE 609 

The skin of the affected half of the face becomes wrinkled, the 
teeth become loose, the eyebrows fall out. The secretion of the 
sebaceous glands is diminished or abolished. The face is drawn 
toward the sound side, rendering the contrast between the two 
sides striking. 

A similar facial asymmetry is encountered in children as a de- 
velopmental defect, often in association with congenital tor- 
ticollis. 

Facial hemihypertrophy, the opposite condition, in which one 
side of the face is enlarged, occurs as an anomaly in the develop- 
ment of the face, sometimes associated with hemihypertrophy of 
the entire half of the bod}^ 

THE COLOR OF THE FACE 

Pallor of the face occurs in anemia, ischemia, the edema of 
Bright 's disease, and transiently as the result of sudden fright. 

Flushing of the face may be transient and due to vasomotor 
disturbance, or may be persistent, notably in the early stage of 
acute fevers, as yellow fever. The flushed cheek of pneumonia 
and the bilateral flushing of tuberculosis have been described, A 
flushed face accompanies excessive cardiac hypertrophy, and in 
one form of essential anemia, namely, chlorosis rubra, is a 
marked feature of the disease. In apoplectic attacks and in the 
early stages of alcoholic intoxication the face is flushed. 

Cyanosis, or bluish discoloration, particularly noticeable in the 
lips and ears, occurs in uncompensated heart disease. A similar 
bluish discoloration of the face is symptomatic of poisoning with 
coal tar products. 

Yellowish discoloration of the entire face is suggestive of the 
cachexia of malignant disease, syphilis, or chronic malaria. A 
similar hue accompanies chronic constipation with inactive liver, 
certain cases of exophthalmic goiter and Addison's disease. A 
lemon yellow color of the face and body, with maintenance of the 
subcutaneous fat of the body, occurs with pernicious anemia. 

Bluish discoloration, or argyria, occurs in cases of chronic sil- 
ver poisoning. 

Brownish, muddy patches upon the face, termed chloasma, fre- 
quently develops in pregnant women and in women with uterine 
or ovarian disease. 



610 PHYSICAL DIAGNOSIS 

SPASM OF THE FACE 

Spasm of the facial muscles occurs as a result of functional or 
organic disorders. It may be tonic or clonic, unilateral, or bi- 
lateral. It is more frequently encountered in women than in 
men. Among the conditions in which facial spasm possesses diag- 
nostic significance may be mentioned: 

Habit Spasm. — This spasm occurs in neurotic children, 
particularly in young girls. It is intensified by excitement or 
examination. It may consist in the rapid winking of an eye or 
the drawing up of one corner of the mouth. The neck muscles 
are frequently involved, the head being given a quick shake at 
the time of the winking. 

Convulsive Tic. — This is a very sudden spasm of the facial 
muscles, frequently involving the brachial muscles as well. The 
spasmodic movements may be almost constant or may occur in 
paroxysms. In extreme cases the spasm may involve all the 
muscles of the body, the movements being very irregular and 
violent. The spasm is often accompanied by explosive utterances, 
echolalia and coprolalia. 

Blepharospasm. — This is a sudden tonic contraction of the 
orbicularis palpebrarum muscle, causing partial or complete 
closure of the eye. More commonly the spasm affects the lateral 
facial muscles also, producing constant twitching of the side of 
the face. Usually unilateral, blepharospasm may be bilateral. 
The spasm is increased by emotional excitement and voluntary 
movement of the muscles of the face. If not reflex from irrita- 
tion of the conjunctiva or cornea by a foreign body, it indicates 
involvement of the facial nerve. 

Chorea. — Chorea produces arrhythmical jerking contractions 
of the facial muscles. It is accompanied by the other symptoms 
of the disease, as purposeless movements of the hands and feet. 

Exophthalmic Goiter. — Spasm of the levator palpebrse supe- 
rioris muscle, causing rapid movements of the upper lids occurs 
occasionally in exophthalmic goiter, in Avhich it constitutes Aba- 
die's sign of this disease. 

Tetanus. — Tetanus or lockjaw produces tonic spasm of the 
facial muscles, with the risus sardonicus, or sardonic smile which 
is characteristic of the disease. 



EXAMINATION OF THE FACE 611 

Unilateral clonic spasm of one or more facial muscles points 
to irritation of the facial region of the cortex of the brain or to 
irritation of the facial nerve trunk in its course or at its exit by 
tumor or aneurysm of the vertebral artery. 

THE FOREHEAD 

The forehead should be examined for scars, skin eruptions, and 
nodular swellings. 

Scars upon the forehead may be indicative of former trauma- 
tism or of the eruption of syphilis. 

Eruptions. — The forehead is subject to many cutaneous erup- 
tions, notably those of measles, smallpox, and syphilis, in which 
last named disease it constitutes the so-called corona veneris. 

Nodular swellings of the forehead may be indicative of gland- 
ers, trichinosis, syphilitic periostitis, or tumor of the cranial 
bones. 

THE EYES 

The Eyelid 

Edema.^ — Edema of the lids with puffiness, occurs in connec- 
tion with the edema of nephritis and in anasarca due to cardiac 
disease or hepatic cirrhosis. Edema of the lids is also noticed 
during the active stage of pertussis, severe coryza, erysipelas, 
cerebral thrombosis, and in arsenic and iodine poisoning. Slight 
puffiness and edema of the lids upon arising in the morning is 
noted in certain persons as a normal phenomenon. 

Duskiness of the lids and the infraorbital region is symptomatic 
of uterine and ovarian disease, pregnancy, anemia and exhausting 
disease, the molimina of menstruation, and it is said masturba- 
tion. 

Xanthoma is a small, slightly elevated, flattened lipomatous 
new growth which is occasionally encountered on the eyelids of 
diabetic patients. 

Ptosis. — Ptosis of the upper lid is usually due to syphilitic 
paralysis of the oculomotor nerve. Usually unilateral, ptosis 
may be bilateral. A bilateral ptosis of brief duration sometimes 
is seen in anemic and overworked women. Ptosis of the lid oc- 
curs with acute encephalitis and as a congenital condition. 



612 PHYSICAL DIAGNOSIS 

Hordeolum. — A hordeolum or stye is a small abscess in the lid 
margin, situated at the root of an eyelash upon the anterior mar- 
gin of the lid. Styes are acute, run a short course, but are prone 
to recur repeatedly. 

Blepharitis Marginalis. — Blepharitis marginalis, inflammation 
of the lid margin is characterized by the formation of a series of 
scales or crusts along the lid margin, which upon removal ex- 
pose a red, glazed surface. As the scales adhere to the lashes, 
they are sometimes mistaken for the eggs of pediculi. 

Chalazion. — A chalazion or meibomian cyst is a small hard 
tumor of the upper eyelid, imbedded in the tarsal plate. It re- 
sults from obstruction of a meibomian gland, and is prone to be- 
come inflamed and suppurate. 

Epithelioma. — Epithelioma usually is seen upon the lower lid 
in persons past middle life. A history of long duration is usually 
obtainable. 

Chancre. — The initial lesion of syphilis rarely occurs upon the 
lids. 

Lagophthalmos. — Lagophthalmos, imperfect closure of the eye- 
lids occurs with the exophthalmos of Graves' disease, and as a 
result of partial facial nerve paralysis. 

The Conjunctiva 

Pallor.— Pallor of the conjunctiva is a sign of anemia and calls 
for rather than replaces a blood examination. 

Yellowness of the conjunctiva accompanies jaundice, and points 
to hepatic disorder. 

Subconjunctival hemorrhage may occur during paroxysms of 
cough in pertussis or asthma, or as the result of local trauma. 

Conjunctivitis. — In inflammation of the conjunctiva the mem- 
brane is red and bathed with mucopurulent or purulent dis- 
charge. Conjunctivitis may result from local infection, or may 
accompany the acute infectious diseases. 

The Globe 

Exophthalmos. — Exophthalmos, or protrusion of the globe of 
the eye, may be indicative of hemorrhage into the orbit, paralysis 
of the ocular muscles, thrombosis of the superior longitudinal 
sinus, tumor of the orbit or superior maxillary bone pushing the 
globe forward, or of exophthalmic goiter. Exophthalmos may be 



EXAMINATION OF THE FACE 613 

unilateral or bilateral, the latter constituting one of the cardinal 
symptoms of exophthalmic goiter. 

Von Graefe's sign of exophthalmic goiter consists in the in- 
ability of the upper lid margin to accurately follow the sclero- 
corneal junction downward during downward rotation of the 
globe of the eye. 

Enophthalmos. — Recession of the globe of the eye into the 
orbit, enophthalmos, occurs in exhausting diseases, particularly 
those which are associated with the loss of tissue fluids, as cholera. 
Enophthalmos is also caused by absorption of the orbital adipose 
tissue during chronic wasting disease, notably in tuberculosis, 
diabetes, marasmus, and the cachexia of malignant disease. 

Position of the Globe. — During epileptic seizures and hysterical 
coma the globes of the eyes rotate and turn upAvard. In hydro- 
cephalus the globe looks doAVUAvard, while folloAving cranial in- 
juries both globes look toward the side of the injury (conjugate 
deviation). 

Oculocardiac Reflex. — Gentle pressure upon the eyeball of a 
normal subject produces a perceptible slowing of the pulse through 
vagus inhibition. This is a true reflex, the afferent impulse incited 
by pressure upon the globe of the eye being transmitted through 
the ophthalmic division of the trigeminal nerve to the Gasserian 
ganglion and thence through the larger root of the fifth cranial 
nerve to its root of origin. Thence the impulse is transmitted 
downward to the nucleus of origin of the vagus nerve, resulting 
in tonic efferent impulses from this center causing inhibition of the 
cardiac rate. 

Abolition of this reflex indicates a break in the reflex arc at 
some point. Such abolition is noted in cerebrospinal syphilis 
and paresis. Abolition of this reflex is one of the earliest signs 
of syphilitic involvement of the central nervous system, and it 
is a sign which is readily elicited by the general practitioner. 
(Auer.) 

Cornea and Sclera 

Arcus Senilis. — The arcus senilis is a grayish line at the sclero- 
corneal junction which partially encircles the cornea. Present 
in many elderly persons the arcus senilis is particularly frequent 
in arteriosclerosis and chronic nephritis. 

Interstitial Keratitis. — Inflammation of the interstitial tissue 
of the cornea, leading to partial opacity of this structure or to 



614 PHYSICAL DIAGNOSIS 

small pinkish ''Salmon Patches" is nearly always a sign of 
hereditary syphilis. The condition is usually bilateral, affect- 
ing children between 5 and 15 years of age, girls being more 
frequently attacked than boys. 

Ulceration. — Comparatively large ulcers of the cornea are ap- 
parent as losses of the surface epithelium; while minute ulcers 
may require the instillation into the eye of a few drops of Fluores- 
cin, which stains the ulcer a bright yellow-green. Corneal ul- 
ceration frequently develops during the exposure of the cornea 
as a result of the exophthalmos of Graves' disease; and in cases 
in which the cornea is insensitive owing to disease of the oph- 
thalmic division of the fifth cranial nerve. Corneal ulcer is prone 
to develop during prolonged fevers when the patient lies long 
Avith the eyes only partially closed. 

Opacity. — Corneal opacity may result from the repair of a 
corneal ulcer, from interstitial keratitis, or as a result of Pannus. 
Corneal opacity sometimes develops during the course of scrofula 
or chronic malaria. 

Staphyloma. — Staphyloma, a bulging of the cornea, usually is 
a sequence of w^eakening of the cornea by deep ulceration, par- 
ticularly in connection with gonorrheal ophthalmia. 

Yellow Sclerotics. — Yellow discoloration of the sclerotics occur 
in jaundice from hepatic disorder. Small, circumscribed, yel- 
lowish patches, Pinguecula, are innocent growths springing from 
the ocular conjunctiva. 

Bluish Sclerotics occur in connection with chlorosis, in which 
they contrast markedly with the greenish discoloration of the 
skin; also in nephritis, and Addison's disease. 

Scleritis.— In inflammation of the sclerotic coat of the eye small 
bluish or purplish elevations are left upon the sclerotics. 

THE NOSE 

Shape. — The shape of the nose is altered by a growing tumor 
within the nasal cavities, or from the adjacent bones of the face. 
In cretinism and myxedema the nose is flattened and negroid. 
In syphilis in certain instances the nasal bridge is destroyed 
with the production of a characteristic deformity, the saddle 
nose. 

Redness. — Redness of the nose, aside from being commonly 
associated with a history of chronic alcoholism, is observed in 



EXAMINATION OF THE FACE 



615 



lupus erythematosus, in circulatory disturbances, chronic di- 
gestive disorders, and in amenorrhea. 

Epistaxis. — Discharge of blood from the nose is frequently a 
sign of incipient typhoid fever. A discharge of blood mixed with 
cerebrospinal fluid occurs with fracture of the base of the skull. 
Discharge of blood from the nose may signify foreign bodies 
in the nose, acute catarrh, local hyperemia from cardiac dis- 
ease, local ulceration which may be simple, carcinomatous, or 
syphilitic, or hemorrhagic diseases as hemophilia, scurvy, or 
purpura hemorrhagica. 




Fig. 264. — Saddle-nose. (From Eisendrath.) 



Pseudomembrane. — A pseudomembrane develops in the nose 
in nasal diphtheria, a condition which is associated with con- 
siderable swelling of the associated lymph glands. The pseudo- 
membrane may spread to the skin of the face, the conjunctiva, 
or the antrum of Highmore. 

Adenoid Vegetations. — In the presence of adenoid vegetations 
in the nasopharynx the nose is but poorly developed, the nos- 
trils appearing small and pinched. 

Ulceration. — A chronic ulcer on the ala of the nose may be 
tuberculous, carcinomatous or syphilitic. 



616 



PHYSICAL DIAGNOSIS 



THE LIPS 

Pallor of the lips suggests but does not prove the presence 
of anemia. 

Cyanosis, or blueness of the lips, if not due to the ingestion of 




Fig. 265. — Mucous patches. (From Hazen.) 




Fig. 266. — Chancre of the lip of one month's duration. (Frum Hazen.) 



large doses of coal-tar products, is indicative of regurgitant heart 
disease or pulmonary disease of an obstructive nature as em- 
physema and pneumonia. 



EXAMINATION OF THE FACE 



617 



Parted lips, when dry and cj^anotic indicate tlie dyspnea of 
cardiac or pulmonary disease. Parted lips in a child with a 
small, pinched nose is suggestive of adenoid vegetations in the 
nasopharynx. 

Loose, pendulous lower lip accompanies chronic bulbar palsy, 
and less frequently is seen with diphtheritic palsy. 

Herpes of the lips, herpes labialis, occurs with pneumonia 
most frequently, less frequently with malaria, and typhoid fever, 
and other febrile affections. 

Enlargement of the lips accompanies angioneurotic edema, 




Fig. 267. — Prickle-celled carcinoma of the lower lip in a young man, which arose 
after treating a clinically benign lesion with caustic pastes. (Gilchrist's collection.) 
(From Hazen.) 



local abscess formation, and phlegmonous inflammation, and 
obstruction of the lymphatics draining the lips, macrocheilia. 

Rhagades, or fissures of the lips, usually affect the lower lip 
near its center, in cold dry Aveather. Similar fissures develop- 
ing upon the lips near the angle of the mouth in a child are good 
signs of hereditary syphilis. 

Mucous Patch.— Flat, whitish sores near the angles of the 
lips with sharply defined borders, are mucous patches of 
syphilis. 

Chancre. — An indurated sore on the lip, particularly when de- 



618 



PHYSICAL DIAGNOSIS 



veloping in a young person, and associated with enlargement of 
the associated lymph glands suggests the initial lesion of 
syphilis. 




Fig. 268. — Double harelip and cleft palate. (From Fisendrath.) 




Fig. 269. — Case of complete double cleft in which at birth a tooth hung from the lateral 
margin of the alveolar cleft by a thin pedicle of soft tissue. (From Blair.) 

Epithelioma. — A chronic irregular ulcer at the mucocutaneous 
junction of the lower lip in a person past middle life with en- 
largement of the lymph glands at the angle of the jaw, is sug- 
gestive of epithelioma. 



EXAMINATION OF THE FACE 



619 




Fig. 270. — Complete double cleft of the lip. This is here accompanied by a double cleft 
of the palate. The intermaxillary bone carries three incisors. (From Blair.) 




Fig. 271. Noma. A piece has been removed from the left cheek for examination. 

(From the Hunterian Museum, London.) (From Blair.) 



620 PHYSICAL DIAGNOSIS 

Hare-lip is recognized as a vertical slit or cleft in the upper 
lip on one or both sides of the median line. The cleft may be 
small and confined to the lip, or may be associated with cleft- 
palate, club-foot or other deformity, t; 

Noma, or cancrum oris, is recognized as a gangrenous mass of 
tissue involving the lip and adjacent surface of the cheek ac- 
companied by a very foul odor. Occurring after measles and 
diphtheria, it is frequently a sequence of ulcerative stomatitis. 

THE BREATH 

Foul Breath. — A foul breath may be caused by carious teeth, 
diseased gums in pyorrhea alveolaris or mercurial poisoning, 
follicular tonsillitis, ulcerative or gangrenous stomatitis, or gan- 
grene of the lung. 

Uremic Breath. — In uremia the breath has a urinous or ammo- 
niacal odor. • 

Diabetes. — Diabetes mellitus imparts a sweetish, fruity odor to 
the breath, the acetone breath. 

THE TEETH 

Premature and delayed dentition possesses diagnostic signifi- 
cance. The former suggests hereditary syphilis, while the latter 
accompanies rickets, cretinism, and disorders of nutrition. 




Fig. 272. — Hutchinson's teeth. (Courtesy of Drs. Fordyce and MacKee.) (From Sutton.) 

Early Decay. — In children early decay of the teeth occurs in 
association with rickets and gastrointestinal digestive disorders. 
In adults carious teeth occur in pregnancy and diabetes mellitus 
as well as in chronic phosphorus poisoning. 

Loosening- of the teeth, with spongy bleeding gums, occurs in 



EXAMINATION OF THE FACE 621 

scurvy and mercurial poisoning. In pyorrhea alveolaris the 
teeth are loosened. 

Hutchinson Teeth. — In hereditary syphilis the upper central 
incisors may present each a notch in its free border. These teeth 
are small and separated by distinct intervals. It affects the per- 
manent and not the deciduous teeth. 

Grinding of the teeth during sleep in children is observed in 
connection with rickets and derangements of digestion. 

THE GUMS 

Blue Line. — A blue line on the margin of the gum is indicative 
of chronic lead poisoning. In the early stages of the intoxication 
the line is not continuous, but occurs as a series of blue dots at the 
base of the teeth. The line may extend along the entire length 
of the gum, or may be limited to the bases of a few of the front 
teeth in either jaw. 

In chronic copper poisoning a blue or greenish line develops 
along the roots of the teeth. 

Red Line. — A red line along the gingivodental margin occurs 
with pyorrhea alveolaris, gingivitis, frequently in diabetes, and 
it is said in tuberculosis. 

Spongy Gums. — In ulcerative stomatitis the gums are swollen, 
spongy, of deep red or purple color, with a line of ulceration ad- 
jacent to the incisors, sometimes extending to all the teeth. 

In scorbutus the gums are spongy, bleed easily, and the teeth 
are loosened. In mercurial poisoning the gums are spongy, there 
is excessive salivation, and fetid breath. 

In pellagra the gums are spongy, and assume a cerise color. 

Epulis. — An epulis is a small, soft tumor springing from the 
gums or alveolar process of the superior maxillary bone. It is 
usually a giant-cell sarcoma. 

THE TONGUE 

Size of the Tongue. — Hypertrophy of the tongue occurs in in- 
fants as a congenital condition, the tongue reaching such enor- 
mous size that it cannot be contained in the mouth. Acquired hy- 
pertrophy of. the tongue is seen in acromegaly, myxedema, and cre- 
tinism, in acute glossitis, and as a result of lymphatic obstruction, 
macroglossia. 

Atrophy of the tongue occurs as a part of glossolabiolaryngeal 



622 PHYSICAL DIAGNOSIS 

palsy. Unilateral atrophy of the tongue* may accompany facial 
hemiatrophy and as a result of hemorrhage or tumor developing 
in close proximity to the hypoglossal nucleus. 

Movements of the Tongue. — The manner in which the tongue 
is protruded upon request as well as the integrity of its move- 
ments during mastication and speech should be carefully noted. 
Thus in nervous and neurasthenic subjects the tongue is pro- 
truded quickly upon request, whereas in typhoid states the pro- 
trusion is very slow and tardy. 

In unilateral paralysis of the tongue, accompanying hemiplegia 
or unilateral hypoglossal palsy the tongue deviates from the 
median line when protruded. In bilateral paralysis of the tongue, 
as a result of bulbar paralysis, or symmetrical lesions of the cor- 
tex or supranuclear tracts, the tongue lies upon the floor of the 
mouth and cannot be protruded. 

Inability to perform the finer movements of the tongue con- 
cerned in mastication and speech is an early sign of glossolabio- 
laryngeal paralysis, or true bulbar palsy. A similar impairment 
of the movements of the tongue accompanies pseudobulbar paral- 
ysis, a state in which the central lesion is not situated in the 
medulla, but in the lingual fibers from the cortex above the me- 
dulla. This condition of pseudobulbar palsy is not accompanied 
by atrophy of the tongue, which only occurs in true bulbar palsy, 
or glossolabiolaryngeal paralysis. The absence of lingual 
atrophy in the former indicates that the causative lesion is in the 
upper neurone, above the nucleus. 

Tremor. — A coarse or fine tremor of the tongue upon protrusion 
accompanies many organic nervous diseases and typhoid states, 
and exhausting fevers. In organic nervous involvement the tre- 
mor is constant, whereas in typhoid states it only develops upon 
protrusion of the tongue. 

Spasm. — Tonic spasm of the tongue accompanies Thompsen's 
disease, or myotonia congenita. A similar tonic spasm of the 
tongue occurs from reflex irritation of the trigeminal nerve. 
Clonic spasm of the tongue is noted in connection with chorea, 
epilepsy, puerperal melancholia, multiple sclerosis and paresis. 

Ulceration. — Ulceration of the dorsum of the tongue may be in- 
dicative of simple ulceration, tuberculosis, syphilis, or carcinoma. 

Simple ulceration results from local trauma or irritation. Not 
infrequently in young children an ulcer of the frenum is noted, 
resulting from the irritation of the sharp edges of the lower 
central incisor teeth. 



EXAMINATION OF THE FACE 



623 



A tuherculoKS ulcer of the tongue may be oval, linear, or stellate. 
The surface of the nicer is pale and uneven, covered with grayish 
exudate, presenting no evidences of acute inflammation. It is usu- 
ally accompanied by tuberculosis of the cervical lymphatic glands. 






Fig. 273. — Illustrating tuberculous lesions of the tongue, A and B in the same indi- 
vidual, healing after two and one-half years' treatment; C, on the dorsum of the tongue 
of an individual suffering from active advanced tuberculosis; no signs of healing shown, 
patient dying of the disease a few months later. (From Pottenger.) 

A syphilitic ulcer of the tongue produces a chronic dissecting 
glossitis characterized by multiple fissures situated principally 
upon the lingual edges, but crossing the dorsum of the tongue in 
various directions. The cervical lymph glands are commonly 
enlarged. 



624 



PHYSICAL DIAGNOSIS 



A carcinomatous ulcer of the tongue is solitary, with induration 
of the surrounding tissues, somewhat simulating a chancre; but 
the ulcer does not disappear under antisyphilitic therapy. The 
carcinomatous ulcer is apt to develop in elderly persons, and the 
accompanying glandular enlargement appears more tardily than 
in the other lingual ulcers. 

Geographical Tongue. — In the geographical tongue there are 
one or more patches upon the dorsum in which the surface 
epithelium has desquamated, the patches extending at the periph- 
ery while healing at the center, pursuing a circinate course 




Fig. 274. 



'Cobblestone tongue" due to gunimous deposits two years after infection. 
(From Hazen.) 



over the dorsum, two or more patches frequently coalescing. Oc- 
curring in undernourished children and adults, the geographical 
tongue possesses little significance. 

Leucoplakia. — In leucoplakia irregularly shaped plaques of 
thickened epithelium appear upon the dorsum of the tongue. The 
plaques are smooth, pale, slightly elevated above the surrounding 
surface of the tongue, one to two centimeters in diameter, and 
nonulcerative. Their recognition is important in that they have 
become the starting point of carcinoma of the tongue. 

Smoker's Patch. — In persons who use tobacco to excess a round 
or oval patch is sometimes encountered upon the dorsum of the 



EXAMINATION OF THE FACE 625 

tongue near the tip, slightly elevated, red or pearly in color, 
smooth, and with no tendency to ulceration. 

Cysts. — Mucous and blood cysts occasionally develop in the 
tongue. Rarely the cysticercus cellulose, the larva of the taenia 
solium may produce a cyst upon the under surface of the tongue, 
or an echinococcus cyst may be encountered in this region. Also 
a ranula, due to obstruction and dilatation of the ducts of 
Blandin-Nuhn's glands may be found on the under surface of the 
tongue near the tip. 

Thrush. — In thrush the dorsum of the tongue is covered or 
studded with small, white flakes, resembling closely deposited 
flakes of coagulated milk, but differing from them in that they 
cannot be wiped off; and, if removed, leave bleeding points. 

Indentation of the edges of the tongue by the teeth, is noted 
during prolonged fevers when the hygiene of the oral cavity is 
not properly practiced. In pellagra there are similar indenta- 
tions in the deep red border of the tongue occurring Vvdth this 
disease. 

Pellagra. — In pellagra the tongue presents a fiery red border 
and tip, showing indentations corresponding to the teeth with 
which it is in contact. Frequently small circumscribed sloughs 
are encountered upon the borders of the tongue, corresponding to 
areas of epithelial denudation. The gums are spongy and of a 
cerise color, while the mouth is the site of a stomatitis of variable 
intensity. The condition of the tongue and buccal mucosa is in- 
tensely painful. 

Dryness of the Tongue. — The tongue in health is kept mois- 
tened with the salivary secretions and the buccal secretions. 
When this secretion is inhibited during acute fevers, the admin- 
istration of atropine, or from excessive loss of body fluids inci- 
dent to prolonged diarrhea and profuse hemorrhage the tongue 
is abnormally dry, and not infrequently covered with a thick 
brown coat. 

Color. — The ingestion of various chemicals and drugs and cer- 
tain diseases alter the color of the tongue. The tongue is white 
following the ingestion of mercuric chloride, ammonia, suli)huric 
acid and phenol. The ingestion of caustic potash or soda causes 
reddening of the tongue with evidences of destructive action of 
these substances. Hydrochloric and nitric acids color the tongue 
yellow. 

In Addison's disease and purpura hemorrhagica the tongue not 
infrequently exhibits small nonelevated purple spots; while xan- 



626 PHYSICAL DIAGNOSIS 

thelasma produces yellowish, slightly elevated dots along the 
margins of the tongue. 

In scarlatina the tongue is bright red, the filiform papillse con- 
trasting sharply Avith the slight white furring of the tongue, the 
strawlerry tongue. 

THE BUCCAL CAVITY 

Color. — The buccal mucosa is pallid in anemic states, is exces- 
sively red during local inflammation as in catarrhal stomatitis, 
and is bluish in cyanosis and argyria. 

Moisture. — Excessive moisture of the buccal cavity, incident 
to overactivity of the salivary and buccal glands accompanies 
local inflammation, following the ingestion of massive doses of 
the iodides and mercurial salts, during the early stages of small- 
pox and typhus fever, occasionally during pregnancy, and during 
convalescence from typhoid fever. 

Dryness of the buccal cavity, or xerostomia, owing to temporary 
arrest of the salivary and buccal secretions occurs during acute 
febrile diseases, diabetes mellitus, in mouth breathers and lesions 
of the pons and medulla affecting the integrity of the nervous 
mechanism of the salivary glands. 

Eruptions. — In variola and varicella vesicles may appear upon 
the buccal mucosa, similar vesicular eruptions accompanying her- 
pes buccalis and aphthous stomatitis. Measles is accompanied by 
pathognomonic lesions upon th« mucosa, Koplik's spots. These 
are minute red spots with a bluish-white center, occurring upon 
the inner surface of the cheek opposite the molar teeth. The 
number of the spots varies ; there may be only one or two or the 
mucosa may be fairly studded with them. The spots occur early, 
disappearing with the inception of the exanthem. 

Mucous Patch. — The mucous patch of syphilis is frequently en- 
countered upon the buccal mucosa. In all suspicious cases a care- 
ful search of the mucous lining of the cheek should be made for 
these lesions. 

Noma, cancrum oris, or gangrenous stomatitis, develops as an 
indurated spot upon the mucous lining of the cheek near the 
angle of the mouth, later involving the entire thickness of the 
buccal wall, the gangrenous tissue emitting an especially foul 
odor. 



EXAMINATION OF THE FACE 627 

THE PHARYNX 

111 examining the pharynx the tongue should be gently de- 
pressed with a wooden spatula or other type of tongue depressor, 
while the patient is instructed to utter the word ''AH," which 
lowers the base of the tongue, permitting a good view^ of the 
posterior pharyngeal wall. 

Redness. — Abnormal redness of the pharyngeal wall accom- 
panies acute inflammation of the pharynx, which may be pri- 
mary, or occur with the acute exanthematous fevers, or acute in- 
fectious disease, as influenza and erysipelas. 

Eruptions. — The eruptions of variola, varicella, and of herpes 
buccalis are often distributed generally over the pharyngeal wall. 

Ulceration of the pharyngeal wall is indicative of tuberculosis, 
syphilis, or typhoid fever. 

Bulging of the posterior pharyngeal wall, either in the median 
line or laterally, occurs in postpharyngeal abscess^ which is often 
due to tuberculous disease of the cervical vertebrae. 

Elongated Uvula. — Elongation of the uvula may occur from 
inflammation of the adjacent pharyngeal mucous membrane, but 
it may also be a part of the general edema incident to cardiac or 
renal disease. 

Perforation of the soft palate is usually of syphilitic origin. 

Paralysis of the soft palate may be unilateral or bilateral. 
Paralysis of the palate is detected by olservation of its move- 
ments while the patient speaks, at which time the normal palate 
moves upward. If this normal mobility of the palate is lost on 
one side, the paralysis is unilateral; if both sides remain im- 
mobile, the paralysis is bilateral. Bilateral palatal paralysis is 
not infrequently attended by regurgitation of fluids through the 
nose upon the attempt to swallow. Paralysis of the palate may 
be part and parcel of giossolabiolaryngeal paralysis, may de- 
pend upon cervical caries, or may be due to diphtheritic paralysis. 

THE TONSILS 

Inflammation. — A moderate grade of tonsillar inflammation re- 
sulting in painful deglutition, accompanies most of the acute exan- 
thematous fevers. In acute follicular tonsillitis the tonsils are 
moderately enlarged, red, and studded with minute yellowish 
dots, corresponding to plugs of mucus, epithelium and bacteria 
which can be squeezed from the tonsillar crypts. 



628 PHYSICAL DIAGNOSIS 

Chronic simple enlargement of the tonsils, in which the two 
bodies may almost meet in the median line, occurs occasionally 
in childhood. 

Pseudomembrane. — A pseudomembrane upon the tonsil, per- 
haps involving the pharyngeal wall as well, if not diphtheria, is 
apt to be due to streptococcic inflammation or scarlatina. 

Ulceration. — Ulceration of the tonsil is due to tuberculosis, 
syphilis, or, if in an elderly person, to carcinoma, or in a younger 
subject to sarcoma. 

Peritonsillar Ulceration (Vincent's Angina) — In this disease 
which is a unilateral affection, there is ulceration of the peri- 
tonsillar tissues, with a variable amount of yellowish exudate 
covering the tonsil. There is marked swelling of the submaxil- 
lary lymph glands. 



CHAPTER XXVIII 
EXAMINATION OF THE NECK 

Shape. — Certain variations in the shape of the neck character- 
ize certain diseases. Thus, a short, thick neck suggests hyper- 
trophic emphysema, and is a constant accompaniment of the 
barrel chest of this disease. Similarly in plethoric patients the 
neck is short and thick. A long, slender neck, on the other hand, 
is frequently observed in phthisical patients. 

Rigidity. — This may be caused by tuberculous disease of the 
cervical vertebra or rheumatism of the muscles of the neck. 
Tender, enlarged cervical glands or boils or carbuncles may 
cause the patient to hold the neck rigid. As previously stated, 
retraction and rigidity of the neck occur in meningitis, tetanus, 
and strychnine poisoning. Rigidity of the neck with fixation of 
the head is also observed as a result of arthritis deformans, spas- 
modic torticollis, and due to scars from extensive burns of the 
neck. 

Prominent Sternomastoids. — Abnormal prominence of both 
sternomastoid muscles is usually a sign of long continued dysp- 
nea, due to pulmonary or cardiac disease. An undue prominence 
of one sternomastoid may be caused by spasmodic torticollis, a 
tumor, cyst, or abscess of the muscle. 

Torticollis. — This is a spasm, usually tonic, rarely clonic, of 
the sternomastoid and trapezius muscles. Its cause is occasionally 
irritation of the spinal accessory nerve vhich supplies these mus- 
cles, by cicatrices or enlarged glands. Most cases, however, occur 
without assignable cause. Congenital torticollis is caused by 
congenital shortness of one sternomastoid and is not due to spasm 
in any sense. 

Deflection of Larynx and Trachea. — The larynx and trachea, 
the latter overlaid by the thyroid gland, occupy the median line 
of the neck. Deflection of these structures to one or the other 
side may be due to atrophy of the muscles on one side of the 
neck, to tumor or aneurysm in the adjacent tissues, or to disease 
of the thoracic viscera. Of the last named factors, fibroid phthisis 
is very important, the structures being deflected toward the side 
of the cirrhotic lung. 

629 



630 



PHYSICAL DIAGNOSIS 




Fig. 275. — Goiter. (From Woolley.) 




Fig. 276. — Palpation of thyroid gland. 



EXAMINATION OF THE NECK 



631 



Movements of the Larynx and Trachea. — Marked inspiratory 
descent of the larynx occnrs in laryngeal stenosis. Normally the 
larynx descends slightly during inspiration and rises to a similar 
degree during expiration. When this mobility is abolished in a 
dyspneic patient the cause of the dyspnea is below the larynx 
as, for instance, pressure on a bronchus by enlarged glands or 
aneurj^sm. 

Tracheal Tug". — This is an important sign of aneurysm of the 
thoracic aorta, and has been discussed in a previous section. 




Fig. 277. — Palpation of submaxillary and submental glands. (From Eisendrath.) 



Thyroid Gland. — This gland may be increased in size or it 
may be diminished in size. 

Enlargement of the thyroid may involve one or both lobes. 
The degree of enlargement varies. There may be a small local- 
ized swelling at one point, or the entire gland may be found 
greatly enlarged, exerting dangerous pressure upon the trachea, 
carotid arteries, and nerves. The consistence of the enlarged 
gland varies. In the fibrous forms of goiter the gland is hard, 
while in the cystic form it is soft and may fluctuate. Some- 
times a thrill may be detected on palpating the gland, accom- 
panied by a systolic murmur, due to the increased vascularity 



632 



PHYSICAL DIAGNOSIS 



of the gland. An enlarged thyroid gland moves with the trachea 
during deglutition. 

The significance of a thyroid enlargement varies with the 
cause. It may be due to abscess following an infectious disease, 
or to malignant growth. If due to simple hypertrophy of the 
gland, the tumor will usually appear during pregnancy, and dis- 
appear spontaneously after labor. If fluctuation is detected, it is 
probably a cystic goiter or an abscess of the gland. If the en- 
largement be due to exopththalmic goiter it wdll be associated 
with the cardinal symptoms of this disease, as tachycardia, 
exophthalmos, and tremor. 

Atrophy of the thyroid gland, revealed by the presence of a 











"i#*^i^ 




Fig. 278. — Congenital hemangioma of neck. (From Fisendrath.) 



depression in the normal position of the gland, occurs in cretinism 
and myxedema. 

Enlarged Glands. — Enlarged lymph glands in the cervical re- 
gion may have a varied significance, the significance varying with 
the location of the glands involved and with the state in which 
they are found; namely, whether hard or soft and fluctuating, 
whether single and individual or matted together in a mass. 
Among the causes of glandular enlargement in this region may 
be mentioned the following conditions. 

The lymph glands at the angle of the jaw may enlarge from 
follicular tonsillitis, diphtheria, scarlatina, measles, German 



EXAMINATION OF THE NECK 



633 



measles, varicella and smallpox; also in erysipelas, glanders, 
whooping cougli, and retropharyngeal abscess. In these condi- 
tions the glands are acutely tender for a period and usually un- 
dergo resolution without abscess formation. 

The submental glands, just below the chin may enlarge 
as a result of carious teeth, stomatitis, syphilis, mumps, cancer 
of the lower lip or anterior portion of the tongue. This group of 
glands is often enlarged in cases of actinomycosis. 





Fig. 279. — Hodgkin's disease. 



The parotid lymph glands enlarge in mumps, and diseases of 
the upper pharynx and skin of the face, as well as in malignant 
disease of the parotid gland. 

The occipital glands are enlarged in German measles, often the 
only group attacked in this disease. Enlargement of this group of 
glands is also a valuable sign of syphilis, and occurs also in cases 
of pediculosis of the scalp. 

Tuberculosis of the cervical glands causes glandular enlarge- 
ment, particularly in the glands under the jaw. The glands 
tend to become adherent to the cutaneous structures and often 
suppurate. 



634 PHYSICAL DIAGNOSIS 

Hodgkin's disease causes glandular eniargement in the lymph 
glands of the neck, of long standing, involving also the glands of 
the axilla, groin, and shoAving slight splenic enlargement. 

Lymphatic leukemia is a cause of enlargement of the cervical 
lymph glands. 

Enlargement of the lymph glands above the left clavicle points 
to cancer of the stomach. 

The condition of the glands and the duration of the enlarge- 
ment possess diagnostic significance. Thus, acute painful cases 



•; 



Fig. 280.— Branchial cyst. (From McFarland.) 

of short duration are probably due to a tonsillitis, or the exan- 
themata. Chronic cases, of long standing, may be due to tuber- 
culosis, syphilis, or Hodgkin's disease. In tuberculosis the glands 
are matted together with tendency to suppurate. In syphilis 
they are hard and small. In Hodgkin's disease the glands are en- 
larged, but remain separate, and do not tend to suppurate. 

Abscess. — An abscess in the cervical region is almost certainly 
of tuberculous origin, being the result of tuberculosis of the 
cervical lymphatic glands or of Pott's disease. 



EXAMINATION OF THE NECK 635 

Scars. — Scars in the neck are usually the result of cervical tu- 
berculosis, surgical procedures or trauma. 

Branchial Cysts and Fistnlae. — Branchial cysts and fistulas, 
resulting from imperfect closure of the embryonic branchial 
clefts, are encountered in rare instances. A branchial cyst is 
formed by closure of the pharyngeal and cutaneous surfaces of 
the cleft without closure of the intervening mesoblastic tissues. 
Branchial fistulse may be complete or incomplete, depending 
upon the degree of fusion of the embryonic clefts, the incomplete 
being represented by diverticula, either external or internal, 
opening into the pharynx. 

Ludwig's angina, a painful indurated swelling beneath the angle 
of the jaw, due to septic infection of the tissues surrounding the 
submaxillary gland, is an occasional cause of dyspnea and dyspha- 
gia which may become alarming. 

Woody or ligneous plilegmon, an insidious induration of the sub- 
cutaneous tissues of the neck, involving the lateral or anterior 
aspect of the cervical region, is occasionally encountered. In 
some instances the structures are indurated from the jaw to the 
clavicle ; the condition is attended by little pain and no fever. 



SECTION II 
EXAMINATION OF THE HAND AND ARM 



CHAPTER XXIX 

THE HAND 

THE NAILS 

Pallor. — Pallor of the nails is a sign of anemia, and it is well to 
bear in mind the rnle laid down by Stephen McKenzie, that when 
pressure upon the tip of the finger completely drives the blood 
from beneath the nail, the red corpuscles are present in only 
half their normal number. 

Cyanosis. — Cyanosis or blueness of the nails is a sign of de- 
ficient aeration of the blood, either due to a failing heart, an ob- 
structive pulmonary lesion, or the ingestion of coal tar products. 
As has been stated, cyanosis appears very early under the nails 
and about the lips. 

White spots in the nails are usually significant of trophic 
changes in the nail ; less commonly they are due to injury of the 
matrix by picking at the base of the nail. 

Capillary Pulse. — The capillary pulse has been described under 
the section upon the examination of the circulatory organs; and 
as stated, is a valuable sign of aortic regurgitation or Corrigan's 
disease. 

Transverse Groove. — A transverse groove on the back of a nail 
is a sign of a recent acute illness. The groove has its incep- 
tion at the base of the nail and its distance from the base 
when observed may indicate when convalescence from the illness 
in question commenced. Thus it requires six months for the 
groove to progress from the base to the free edge of the nail; 
hence, if it be encountered half way between the matrix and the 



EXAMINATION OF THE HAND 



637 



free edge, it is an indication that convalescence began approxi- 
mately three months previonsly. 

Longitudinal ridges in the nails are said to be a reliable sign of 
gouty diathesis. Certainly the ridges are encountered in many 
gouty patients. 




Fig. 281. — Ilypertroplij^ of the nails. (From Hazen.) 




Fig. 282. — Symmetrical atrophy of nails. (Courtesy of Dr. J. C. E. King and Dr. H. G. 
Parker.) (From Sutton.) 



Incurvation of the nails, with or without clubbing of the 
finger-tips is a sign of chronic disease of the heart or pulmonary 
tissues, such as cardiac failure, aneurysm, phthisis, or emphysema. 



638 PHYSICAL DIAGNOSIS 

The incurvation may be lateral or longitudinal, or may occur in 
both directions. 

Hypertrophy of the nails, particularly in the transverse di- 
rection associated with thickening and sometimes with twisting, 
occurs after acute fevers, particularly following typhoid fever, 
in connection with syphilis, and in sclerodactyly. A similar hy- 
pertrophy of the nail may result from eczema, may be encoun- 
tered in a subject with Kaynaud's disease, and in pulmonary 
osteoarthropathy. The nail may be simply hypertrophied with- 
out any defect in its structure (megalonychosis) ; or in addition 
to hypertrophy the nail may be twisted spirally (onychogry- 
posis). 

Atrophy of the nails, with ulceration at the base, occurs in Mor- 
van's disease, a syndrome which develops as a sequence of neuritis 
and syringomyelia. Atrophy of the nail may follow psoriasis of 
the fingers. 

Arrested Growth. — The growth of the nails is impaired or 
ceases on the paralyzed side in hemiplegia. A similar arrest of 
growth of the nails of the paralyzed limb occurs in infantile paral- 
ysis. Arrest of growth of a nail may be detected by staining the 
nails at identical points upon the two hands and observing any 
discrepancy between the growth of the nails. 

Excessive brittleness of the nails is noted in persons of gouty 
diathesis, the nails frequently presenting the longitudinal stria- 
tions which have been described. 

Onychia, ulceration of the nail matrix, occurs in children with 
hereditary syphilis, or scrofula, and it is said in persons who are 
addicted to the chloral habit. 

Paronychia, or whitlow, an acute inflammation of the tissues 
surrounding the matrix of the nail, may be a sequence of local 
trauma or may be caused by lateral hypertrophy of the nail. 

Indolent Sore. — An indolent sore near the root of the nail, if 
indurated and associated with enlargement of the epitrochlear 
lymph glands, is usually a chancre; but may be due to tubercu- 
losis. 

THE FINGERS 

Tophi. — Tophi are concretions of sodium biurate which occur in 
the joints of the fingers in gouty subjects. They are more promi- 
nent on the dorsal surface of the joints, and may break through 



EXAMINATION OF THE HAND 



639 




Fig. 283. — Hebreden's nodes. (From Butler.) 




Fig. 284. — Pulmonary osteoarthropathy. (From Butler.) 



640 



PHYSICAL DIAGNOSIS 



the skin, when they constitute the ' ' chalk* stones ' ' of the disease. 
Enlarged Joints.— Enlargement of the joints of the fingers 
is seen in connection with gout and chronic rheumatism. In 
rheumatism the enlarged joints are often hot and painful. 




Fig. 285. — Arthritis deformans. (From Butler.) 




Fig. 286. — Morvan's disease. (From Butler.) 



Heberden's Nodes. — These nodes, also termed Haygarth's Nodos- 
ities, are knobby enlargements of the proximal ends of the ter- 
minal phalanges. They are noted in gout and in arthritis de- 
formans, in which diseases they are said to be of good prognostic 
significance. 



EXAMINATION OF THE HAND 641 

Clubbed Fingers (Hippocratic Fingers). — Clubbing of the 
terminal phalanges accompanies many chronic diseases of the 
heart and lungs, notably chronic bronchitis, emphysema, phthisis, 
and chronic pleurisy, and uncompensated cardiac disease. The 
nails are commonly incurved. An exaggeration of this condition 
with swelling of the carpal joints is noted in pulmonary osteo- 
arthropathy. 

Distortions of the fingers accompany gout, chronic rheumatism, 
and arthritis deformans. The distortions are not produced merely 
by fixation of the fingers in abnormal positions, but are produced 
by organic changes, in gout by the deposition of sodium biurate 
in the joints, in arthritis deformans by absorption of bone and 
the growth of exostoses. The fingers are most frequently de- 
flected toward the ulnar side of the hand. 

Dactylitis. — Dactylitis is usually a sign of hereditary syphilis, 
less frequently of tuberculosis. In the evolution of the deformity 
a fusiform purple swelling, which is prone to undergo ulceration 
with sinus formation, appears upon one or more of the fingers, 
most frequently involving the proximal phalanges. 

Raynaud's Disease.— In Raynaud's disease, or ''dead fingers" 
the fingers are bluish-black or livid, gangrene occurring in spots 
and leading in many instances to spontaneous amputation of the 
fingers. 

Miorvan's Disease. — In this disease the fingers are the site of 
painless, destructive whitlows, which have their inception ad- 
jacent to the base of the nail, leading to necrosis of the terminal 
phalanges and marked swelling of the fingers. 

SHAPE OF THE HAND 

The shape of the hand varies in different subjects and under 
varying conditions of age and occupation. The broad, heavy 
hand is said to be indicative of a sanguine personality, while the 
slender hand is said to indicate a nervous temperament. Bluish 
dotting of the hand of a coal miner points to the possibility of 
anthracosis, while in old age and in malignant disease and phthisis 
the hand is small and withered. 

Spade Hand. — In acromegaly and myxedema the hand is large, 
with thick fingers and broad nails. In myxedema the hand is 
boggy, but does not pit on pressure; whereas in acromegaly the 
hand is hard, as the basis of the hypertrophy is osseous. 



642 



PHYSICAL DIAGNOSIS 




Fig. 287. — Spade hand. (From Butler.) 







Fig. 288. — Claw hand. (Main-en-grift'e.) (From Fisendrath.) 



EXAMINATION OF THE HAND 



643 



Claw-Hand ( Main-en-griff e). — In amyotropliic lateral sclerosis 
and progressive muscnlar atrophy the proximal phalanges are 
drawn backward toward the wrist, while the second and third 
phalanges are flexed toAvard the palm. The underlying cause 




Fig. 289. — Accoucheur's hand. (From Butler.) 




Fig. 290.- Wru'L-Jrop. (From Fisendrath.) 



of this deformity is a paralysis of the Inmbrical and interosseous 
muscles, causing the proximal phalanges to assume a state of dor- 
sal extension, while the distal phalanges are flexed. 

Hemiplegic Hand. — In hemiplegia the contractures of the arm 



644 PHYSICAL DIAGNOSIS 

and hand are replaced in course of time by permanent deformity. 
The fingers in this deformity are flexed upon the palm, the wrist 
is flexed upon the forearm, while the elbow is retained in a state 
of permanent flexion and applied closely to the side of the 
body. 

Seal-fin Hand. — In chronic gout and rheumatoid arthritis the 
entire hand is deflected toward the ulna as a result of spasm of the 
extensor muscles, imparting to the hand a fancied resemblance to 
the fln of a seal. 

Ape Hand. — This type of manual deformity is the result of wast- 
ing of the thenar and hypothenar muscles in progressive muscu- 
lar atrophy, causing the hand to assume a position in which the 
fingers and thumb are on one parallel plane. 

Accoucheur's Hand. — In this type of manual deformity, which 
occurs in tetany, the thumb is flexed into the palm of the hand, 
while the fingers, flexed at the metacarpophalangeal joints and 
first interphalangeal joints, are extended at the second inter- 
phalangeal articulations and pressed closely upon the thumb. 

Dupuytren's Contracture. — This is a permanent painless flex- 
ure of one finger of one or both hands into the palm. Most com- 
monly the little finger alone is involved, but sometimes the ring 
finger or other fingers are flexed also. Dupuytren's contracture 
results from burns or other injuries to the palmar fascia. 

Ganglion. — A ganglion is recognized as a localized swelling 
upon the dorsum of the hand. It is presumably caused by cystic 
degeneration of a synovial fringe within a tendon sheath. Gan- 
glia are not infrequently tuberculous in origin. 

Wrist-drop.— In wrist-drop the hand hangs powerless from the 
wrist. It is significant of neuritis or paralysis of the musculo- 
spiral nerve. 

TREMOR OF THE HAND 

Intention Tremor. — Intention tremor is a tremor of the hand 
which is converted into coarse shaking movements when the 
patient endeavors to perform any act, such as bringing a glass, 
of water to the lips, or holding a pen to write. Intention tremor 
is a cardinal sign of multiple sclerosis and is sometimes noted in 
hysteria. 

Paralysis Agitans. — In paralysis agitans . the patient is sub- 
ject to a constant tremor of the hands, in which the thumb and 
index finger are held in close proximity to one another or in actual 



EXAMINATION OF THE HAND 



645 



contact, describing a rolling movement as if they were rolling a 
pill (Pill-rolling tremor). The tremor in marked contrast to that 
of mnltiple sclerosis disappears completely during voluntary 
movements of the hands. 

Professional Spasm. — Writers, violin players, and others who 
constantly employ one set of muscles are often troubled with 
painful spasms in the muscles used, incapacitating them for their 
usual occupations. 




^ 



i 
I 




Fig. 291.— Pellagra. 

Athetosis. — This term refers to certain slow and purposeless 
movements of the fingers which are encountered in patients suf- 
fering with organic disease of the central nervous sj^stem. 

Pellagra. — The cutaneous manifestations of pellagra involve the 
extensor aspect of the hand and forearm, producing an eruption 
of an erythematosquamous type. In incipient cases, in the stage 
of initial erythema, the eruption resembles closely ordinary sun- 



646 



PHYSICAL DIAGNOSIS 



burn or solar erythema. In the latter evolution of the disease the 
superficial epithelium takes on a broAvn pigmentation, and 
desquamates in scales. Sensation is lost in the areas of des- 




Fig. 292. — Pellagra in child less than 3 years old. 



quamation. The skin covering the elbows should always be in- 
spected for the eruption. The eruption may involve the dorsum 
of the foot or the face, and rarely the neck or chest. 



CHAPTER XXX 

THE FOREARM AND ARM 

EXAMINATION OF THE FOREARM 

Epiphyseal enlargement of the forearm bones at the wrist is 
indicative of rickets. It is usually accompanied by the rachitic 
rosary and other signs of the disease. 

Enlargement of the lower end of the radius with clubbing of 
the fingers occurs in pulmonary osteoarthropathy the result of 
chronic pulmonary or cardiac disease. 

Enlargements or nodes along the shaft of the radius or ulna 
are usually due to syphilitic periostitis. 

Erythema nodosum occasionally occurs upon the forearm, 
manifesting itself by the appearance of elevated, red, shining 
nodular swellings, which are very painful upon pressure. 

Edema of the forearm, usually affecting the arm as well, results 
from thrombosis of the axillary vein, or from the pressure of me- 
diastinal tumors upon the. subclavian vein. 

EXAMINATION OF THE ARM 

Tumors. — A superficial tumor arising in the arm is most apt 
to be lipomatous. It is often lobulated. A ruptured biceps pro- 
duces a sharp tumor over the lower portion of the arm. A deeply 
seated tumor of the arm is most likely to prove sarcoma of the 
humerus. An acute painful swelling of the humerus foUoAving 
typhoid fever or scarlatina is due to acute periostitis. 

Small nodular elevations upon the humerus are usually the re 
suit of syphilitic periostitis. 

Paralysis. — Paralysis of one arm may be total, the arm hang- 
ing limply, without power of movement, or may be partial. Par- 
tial brachial paralysis may assume one of two types; namely, the 
upper arm type of Duchenne-Erb, or the lower arm type of 
Klumpke. Brachial paralysis may be the result of trauma at 

647 



648 



PHYSICAL DIAGNOSIS 



birth, or may result from compression of \he bracMal plexus by 
a tumor or by a crutch. Some cases are due to a faulty position 
of the arm during anesthesia. The upper arm type of Duchenne- 
Erb involves the deltoid, brachialis anticus^ triceps, supinator 
longus, supinator brevis, and the infraspinatus muscles. The 
patient is unable to adduct the arm, and the forearm remains in 
a position of extension and pronation. The lower arm type of 
Klumpke involves the small muscles of the forearm and hand, 
with inability to move the hand or fingers. 

Rigidity and Contracture. — In hemiplegia the paralysis of the 
arm is spastic and is followed in the course of time by permanent 
contracture. The elbow is maintained in a state of semiflexion, 






Fig. 293. — Lipoma of arm. 



the wrist is flexed upon the forearm, while the arm is often closely 
apposed to the trunk. Spastic rigidity of the arm is often one of 
the earliest signs of chronic hydrocephalus. 

Movements. — In Sydenham's chorea the arms participate in the 
purposeless movements of the head and face. In this form of 
chorea there is no motor weakness; whereas in the so-called hemi- 
paralytic chorea, which is attended by similar purposeless move- 
ments of the arms, the muscular power is usually impaired. Preg- 
nant women occasionally exhibit similar purposeless movements of 
the arms in the so-called chorea gravidarum. 

In paramyoclonus midtiplex there is frequently noted a sym- 
metrical, bilateral, clonic spasm of the muscles of the arms. The 
biceps, triceps, and deltoid muscles are involved. The paroxysm 



EXAMINATION OF THE ARM 649 

is characterized by a series of very rapid clonic contractions of 
symmetric groups of muscles in the two arms, the contractions 
often exceeding a hundred in a minute. Usually of very brief dura- 
tion, the paroxysm may in some cases last for several moments. 

Atrophy. — Atrophy of the muscles of the arm follows the paraly- 
sis of acute anterior poliomyelitis and brachial palsies, conditions 
which involve the lower motor neurone. 

Miner's Elbow. — In this condition there is a swelling overlying 
the olecranon bursa, produced by chronic bursitis of this struc- 
ture, which sometimes yields fluctuation on palpation. 



SECTION III 
EXAMINATION OF THE LOWER EXTREMITIES 



CHAPTEE XXXI 
THE FOOT, LEG, AND THIGH 

THE TOES 

Gangrene of the toes is usually significant of diabetes, arterio- 
sclerosis, or Raynaud's disease. Gangrene of the toes is less 
frequently a sequence of frostbite, local trauma, ergotism, or 
embolism in connection with cardiac disease. 

Perforating Ulcer. — The perforating ulcer, or Mai Perforante, 




Fig. 294. — Gangrene of toes. 

occurring with locomotor ataxia and rarely with diabetes, is a 
deep circular ulcer, usually situated upon the under surface of 
the great toe. 

Gout produces hot tense swelling of the metatarsophalangeal 
articulation of the great toe, which is very sensitive to pressure. 



THE FOOT 

Flat-foot, pes planus, is a flattening or giving way of the nor- 
mal arch of the foot as a result of muscular paralysis, or ligamen- 

650 



EXAMINATION OF THE LEG 651 

tous weakness from long standing or traumatism. Flat-foot is a 
sequence of rickets and infantile paralysis. Flat-foot is recog- 
nized by painting the sole of the foot Avith a colored fluid and 
causing the patient to stand upon a piece of paper, and noting 
whether an impression of the entire sole is left upon the paper. 

Club-foot or talipes is a permanent fixation of the foot in de- 
formity. In talipes equinus the heel is drawn up in such a manner 
that the patient walks upon the ball of the foot or the toes. In 
talipes varus the foot is inverted, the patient walking upon its outer 
border. In talipes valgus the foot is everted and the patient walks 
upon the inner border of the foot. 

Enlargement of the foot with more or less distortion occurs 
in acromegaly, myxedema, and pulmonary osteoarthropathy. 

Erythromelalgia. — In this condition the sole of the foot is very 
red and the seat of burning pain, v/hich is made worse by walk- 
ing and is relieved by elevating the limb. 



THE LEG 

Bowing of the tibiae is most commonly due to rickets, but may 
also be noted in connection with osteitis deformans, moUities 
ossium, and cretinism. 

Nodes. — Red, shining nodes situated over the tibiae, which are 
very painful upon pressure are indicative of erythema nodosum, 
which is more frequently encountered here than in any other 
locality. 

Deep nodular swellings, situated upon the tibia are due to 
syphilitic periostitis, while painless, noninflammatory indurated 
areas distributed over the leg may be gummata. 

Leg Ulcers may be due to varicose veins, but are often due to 
tertiary syphilis, especially if there are multiple annular ulcers 
situated nearer the knee than the ankle. 

Swelling of the Calves in children, associated with loss of mus- 
cular power and difficulty in rising to the erect posture, is indic- 
active of pseudohypertrophic muscular palsy. 

Atrophy of the muscles clothing the anterior and outer aspects 
of the leg is a sign of progressive muscular atrophy. 

Varicose Veins. — Varicosities of the veins of the leg are indic- 
ative in some instances of prolonged standing, or the pressure of 
a pregnant uterus or tumor within the abdomen upon the vessels 
returning blood from the lower extremity. 



652 



PHYSICAL DIAGNOSIS 



Kernig's Sign. — In acute meningitis' It is impossible to fully 
extend the leg upon the thigh. To elicit Kernig's Sign the patient 
should be placed upon the back with the thigh flexed at a right 
angle with the body. An effort is then made to extend the leg, 
bringing it in a line with the thigh. In the presence of meningitis 
it is difficult or impossible to extend the leg because of the 





fc^k] 



Fig. 295.— A case of rickets. 
(From Woolley.) 



Fig. 296. — A case of rickets. 
(From Woolley.) 



marked flexor contracture of the hamstring muscles. In diag- 
nosing meningitis by means of this sign it is necessary to exclude 
sciatica, old contractures, myositis, and tuberculous disease of 
the knee joint. 

Charcot's Joint. — In the course of locomotor ataxia not un- 
commonly as a result of trophic disturbance the knee joint assumes 



EXAMINATION OF THE LEG 



653 



an enormous size, due to chronic inflammation of the synovial lin- 
ing of the joint, which later progresses to the bone itself. The 
enlargement of the joint is always considerable and may become 
enormous. Early in the case the enlargement is due to effusion 
in the joint, but later it is produced by true osseous overgrowth. 
Pain is slight or is entirely absent. Usually affecting the knee- 
joint, the condition may involve the hip joint, and less com- 
monly the smaller articulations. 




Fig. 297.--Showing extreme case of bowlegs. (From Woolley.) 

Housemaid's knee, produced by chronic bursitis of the prepa- 
tellar bursa as a consequence of persistent pressure upon the 
bursa incident to occupation, is characterized by effusion into 
the knee-joint, the effusion pushing the patella upward before it. 
Fluctuation can sometimes be obtained. 



THE THIGH 

Edema of the thigh, affecting the leg and foot as well, possesses 
definite significance depending upon whether it is unilateral or 



654 



PHYSICAL DIAGNOSIS 



bilateral. Thus, edema of one lower extremity may result from 
varicose veins or thrombosis of the femoral vein. Bilateral edema 
points to cardiac insufficiency or hepatic disease producing gen- 
eral anasarca. 

A chronic swelling of the lower end of the femur is often due 
to osteosarcoma of that bone. 



h- './ 


. >"f, 


i 4 


' J 

1 

'1 


i' 






1 


1 ■■* 




^' 


1 
1 



Fig. 298. — Varicose nicer of leg. (From Kisendrath.) 



Intermittent Claudication. — In subjects of arteriosclerosis an 
intermittent lameness may result from deficient circulation to the 
muscles of the thigh. 

Inguinal Adenitis.- — Enlarged glands in the inguinal region may 
indicate venereal disease. In gonorrhea . and chancroid the 
glands are matted and tend to suppurate, whereas in syphilis the 
glands are only moderately enlarged, are hard, and discrete. In- 



EXAMINATION OF THE THIGH 655 

guinal adenitis of long standing is suggestive of tuberculous disease 
of the hip or knee, or Hodgkin's disease. In malignant disease of 
the genitalia there is early inguinal adenitis. 

Swelling in Scarpa's Triangle. — A swelling in this portion of 
the thigh may be due to femoral hernia, or psoas abscess, the lat- 
ter always occupying a position external to the femoral vessels. 

Osteitis Deformans (Paget 's Disease). — Osteitis deformans pro- 
duces bowing of the bones of the thighs, with a consequent diminu- 
tion of the stature. The head in this disease is characteristically de- 
formed, and the contour of the thorax and abdomen is altered. 

Osteomalacia, in its evolution is characterized by bowing of the 
bones of the lower extremity, produced by softening and rarefac- 
tion of the osseous structures peculiar to this disease. 

Rickets. — In advanced rickets there is usually notable bowing 




Fig. 299. — Osteosarcoma of femur. 

of the bones of the lower extremities, leading to ''bowlegs" or 
''knock-knees." In addition there are symmetrical swellings at 
the epiphyses of the long bones. 

Pulmonary Osteoarthropathy. — In this disease the extremi- 
ties of the long bones of the lower extremity, particularly of the 
tibiae, participate in the chronic enlargement which character- 
izes the disease. 

Phlegmasia alba dolens, resulting from thrombosis of the 
femoral vein, produces swelling and edema of the thigh, with 
marked tenderness upon manipulation. The usual cause is puer- 
peral sepsis, but this condition is also a not infrequent complica- 
tion of typhoid fever. 

Paralysis. — Paralysis of one leg if spastic is usually a part of 
a hemiplegia, but may rarely be due to a cortical lesion involving 
the leg center. Flaccid paralysis of one leg is the result of pres- 



656 PHYSICAL DIAGNOSIS 

sure neuritis, chronic lead poisoning, or* anterior poliomyelitis. 
Paralysis of both legs, paraplegia, may result from a cerebral 
lesion, as is the case in Little's disease, or may be due to trans- 
verse myelitis, disseminated sclerosis, or the late stages of loco- 
motor ataxia. 



PART IV 
EXAMINATION OF THE NERVOUS SYSTEM 



SECTION I 
MOTOR AND SENSORY PHENOMENA 



CHAPTER XXXII 
STATION, GAIT, AND MUSCULAR POWER— TREMOR 

Introduction. — The sources of the nervous impulses which ini- 
tiate muscular movements reside in certain specialized cells of 
the cerebral cortex lying anterior to the fissure of Rolando, in 
the nuclei of the cranial nerves at the base of the brain, and in 
the anterior horns of the spinal cord. The experimental work 
of Hughlings Jackson, Hitzig, Ferrier, and Horsley has demon- 
strated that the motor path from the cerebral cortex to the volun- 
tary muscles comprises two segments, or neurones; namely, the 
upper motor neurone, extending from the cerebral cortex to the 
anterior cornual cells, and forming synapses with the cells of cer- 
tain of the nuclei of origin of the cranial nerves; and the lower 
motor neurone, which extends from the anterior cornual cells to the 
muscle in question. 

The axis cylinders of the upper motor neurone, arising from 
cells of the cerebral cortex in the motor area pass downward into 
the white substance of the brain to form the corona radiata. 
They are collected into a compact bundle of fibers which tra- 
verse the internal capsule between the basal ganglia, constituting 
the genu and anterior two-thirds of the posterior limb of this 
structure. Emerging from the internal capsule, the upper motor 
neurone enters the crus cerebri, some fibers at this point crossing 
to the opposite side to form synapses with cells of the nucleus of 
origin of the oculomotor nerve. The upper neurone traverses the 
crus and pons, distributing fibers to all of the motor cranial 

657 



658 PHYSICAL DIAGNOSIS 

nerves of the opposite side and a few fibers to the same 
nerves on the same side, and enters the anterior portion of the 
medulla oblongata to form the pyramid. In the medulla the 
greater number of the fibers constituting the upper motor neu- 
rone cross to the opposite side, forming the decussation of the 
pyramid. These fibers enter the lateral portion of the spinal 
cord as the crossed pyramidal tract, while the smaller number of 
fibers, v^hich did not cross at the decussation, pass dov^n the 
anterior portion of the cord as the direct or uncrossed pyramidal 
tract. The fibers of the crossed and direct pyramidal tracts 
terminate at various levels of the cord by forming synapses v^ith 
the anterior cornual cells, the direct pyramidal fibers crossing in 
the anterior white commissure before forming this junction. 
Thus the upper motor neurone terminates by effecting a junc- 
tion with the cells of origin of the lower motor neurone. It is to 
be noted that impulses arising in the cerebral cortex are all trans- 
mitted to the opposite side of the spinal cord by the upper motor 
neurone. 

The axis cylinders of the lower motor neurone arise in the an- 
terior cornual cells and emerge as the anterior spinal nerve roots 
to form the peripheral nerves which supply muscles on the same 
side of the body. They do not cross. 

The sensory conducting system comprises three neurones. The 
jirst sensory neurone is derived from the ganglia upon the posterior 
nerve roots, the axis cylinders of which divide in a T-shaped 
manner, the longer division going to the peripheral sensory nerve, 
while the shorter branch enters the posterior horn of the spinal 
cord and divides into a long ascending and a short descending 
branch. The longer, ascending branches from this source ascend 
in the posterior columns of the cord to terminate in cells of the 
gray matter of the same side of the cord or to ascend to the 
nucleus gracilis and nucleus cuneatus of the medulla. 

The second sensory neurone arises from the medullary cells or 
the medullary nuclei, form the arcuate fibers, and terminate in 
synapses about the cells of the median and lateral nuclei of the 
optic thalamus of the opposite side. 

The third sensory neurone takes origin from the nuclei of the 
optic thalamus and terminates in the sensory areas of the cerebral 
cortex. 

Gross lesions involving the integrity of the upper motor neu- 
rone in any portion of its course from the cerebral cortex to the 



STATION, GAIT, MUSCULAR POWER 659 

anterior horns of the cord produce spastic paralysis of definite 
portions of the muscular system ; since the regulating or govern- 
ing impulses descending from the cerebral cortex are in abeyance 
and the constant tonic impulses from the anterior cornual cells 
are uncontrolled. Lesions of the lower motor neurone, on the 
contrary, produce flaccid paralysis, with atrophy of the muscle, 
as trophic impulses have their origin in the anterior cornual 
cells. 

The Station. — The station is the attitude of the patient when 
standing at ease in the erect posture. In testing the station the 
patient should be directed to stand with the feet closely ap- 
proximated, and the test should be made first with the eyes 
open and then with the eyes closed. A normal person while 
undergoing this examination will frequently sway slightly from 
side to side, and in cases of muscular weakness, either from ex- 
hausting disease or from neurasthenia, the swaying is more 
marked. But when the swaying movement becomes so extreme 
that the patient is in danger of falling if not supported, the sta- 
tion becomes pathologic. Thus in tabes dorsalis the patient with 
feet closely approximated and the eyes closed sways excessively 
and if not supported is apt to fall (Romberg's sign). 

The Gait. — In many nervous diseases the gait is characteristic 
and gives at once a clue to the correct diagnosis. In observing 
the gait of a patient who is suffering with an organic nervous 
disease the clothing should be removed from the lower extremi- 
ties so that the phenomena attending locomotion may be clearly 
observed. 

The Spastic Gait. — In spastic diplegia due to lesions in the 
lateral pyramidal tracts the lower limbs are stiff owing to an in- 
ability to bend the knees, so that the patient progresses by means 
of short steps, the toes scraping along the floor. The toes of the 
shoes are worn excessively. The presence of a marked ankle 
clonus on both sides communicates a general tremulousness to 
the entire carriage of the patient, who is apt to stumble over 
slight obstacles and fall. 

The Hemiplegic Gait, — The hemiplegic gait is merely a uni- 
lateral spastic gait, the spastic limb during progression de- 
scribing an arc of a circle while the sound limb supports the 
weight of the body. In spastic cerebral paraplegia, or double 
hemiplegia, both limbs describe the arc of a circle during pro- 
gression, each foot in turn being swung outward and planted in 
front of the other with the production of the cross-legged or 



660 



PHYSICAL DIAGNOSIS 



''scissor" gait; the trunk and upper liMbs meanwhile being 
jerked about from side to side in the effort to move the spastic 
members forward. 

The Steppage Gait. — Patients with multiple neuritis with foot 
drop, or with lesions of the lumbosacral region of the spinal 
cord exhibit the steppage gait, a mode of progression in which 




Fig. 300. — Little's disease. (Infantile spastic diplegia.) 




Fig. SOL — Little's disease. (Infantile spastic diplegia.) 



each foot is alternately raised high, the toe thrown upward, 
the foot striking the ground forcibly, as if the patient were con- 
tinually stepping over obstacles in his path. A unilateral 
steppage gait accompanies paralysis of the external popliteal 
nerve. 

The Ataxic Gait. — The ataxic or tabetic gait occurs typically 
in tabes dorsalis, a very similar gait being observed in Fried- 



STATION, GAIT, MUSCULAR POWER 661 

reich's ataxia, and in tumor of the posterior columns of the 
cord. The patient walks on a very broad base, swaying from side 
to side. The foot in progression is raised suddenly from the 
floor, is thrown forcibly forward, and thrown forcibly down ''in 
flail-like fashion," the heel usually striking the floor flrst. The 
patient keeps the eyes fixed steadily upon the floor before him 
in the effort to guide his onward course. He is unable to sud- 
denly stop or start on command or to turn suddenly and re- 
trace his course. Similar ataxia in the upper limbs is demon- 
strable in the inability of the patient to touch the finger-tip to 
the nose, or to accurately approximate the finger-tips with the 
arms before the bodj^ 

The Festinating Gait. — In paralysis agitans the patient moves 
forward with the body inclined somewhat forAvard, advancing 
with short, shuffling steps which become progressively faster as he 
crosses the room. When ordered to turn, the entire body is turned 
en masse. This type of locomotion constitutes the so-called pro- 
pulsion. Retropiilsion may often be elicited in these patients. 
If the patient is quickly pulled backward, and, indeed sometimes 
on merely looking upward, he tends to run backward with short, 
shuffling steps, although the body is invariably inclined forward. 

The Cerehellar or Vertiginous Gait. — In cerebellar disease as- 
sociated with severe vertigo the patient progresses in a very ir- 
regular course, often lurching from side to side. Quite fre- 
quently the patient exhibits a. tendency to reel in a fixed direc- 
tion, forAvard, backAvard, or to one side. This type of progres- 
sion occurs with unilateral cerebellar lesions. In unilateral 
cerebellar tumors the head is not infrequently inclined toward 
opposite side, AAdiile the face is turned slightly toAvard the side 
of the lesion. 

Muscular Power.— A rough estimate of the muscular poAver 
may be made by the ''resistance method," the patient being di- 
rected to perform the function of a given muscle, while the ex- 
aminer endeaA^ors to resist the moA^ement and gauges the amount 
of poAver required in the effort. Variations in muscular poAver 
range from simple weakness to complete loss of power or par- 
alysis. Paralysis may be complete or partial, in Avhich latter 
event it is termed paresis. Paralysis may be spastic, when the 
paralyzed limb is rigid and the muscles unyielding to passive move- 
ment, or flaccid, when the muscles are soft and pliable. Paralysis 
may affect one limb, when the condition is termed monoplegia: it 



662 PHYSICAL DIAGNOSIS 

may affect one entire side of the body, wh^en it is termed hemi- 
plegia; or all four limbs may be involved, when the condition is 
designated diplegia. 

Tremor. — Coarse shaking movement of the muscles of the 
hand upon voluntary muscular effort (intention tremor), ac- 
companies disseminated sclerosis. On the contrary, the fine 
'' pill-rolling" tremor of paralysis agitans is inhibited by volun- 
tary movement. Convulsive tremors involving a small or lim- 
ited group of muscles are observed in Jacksonian epilepsy, v^hile 
fibrillary twitchings accompany progressive muscular atrophy. 
A hemichorea may persist for years as a residual sign of cere- 
bral hemorrhage. 



CHAPTER XXXIII 

SENSORY PHENOMENA— THE REFLEXES 

An accurate sensory examination requires the free and full 
cooperation of the subject of the examination and a refined 
technic upon the part of the examiner. The area under examina- 
tion should be freely exposed and the examination should be con- 
ducted in a chamber which is free from noise and in which the 
temperature is constant and is neither uncomfortably elevated 
nor lowered. The sensory examination should not be unduly 
prolonged; but when any disorder of sensation is detected, its 
exact limits should be determined. In this connection it is im- 
portant that the examiner should refrain from graphically chart- 
ing the limits of the area of dysesthesia upon the skin, as such 
practice serves as a fertile source of suggestion to the subject of 
the examination. 

The course- of the afferent sensory pathway has been outlined 
in a previous section; and from its course it is evident that a 
sensory disturbance may be due to a lesion involving the integrity 
of a peripheral nerve trunk, involving one or more of the tracts 
of the spinal cord, or involving the brain stem or the cerebral 
cortex. The area and distribution of the sensory disturbance will 
in each event serve to localize the site of the causative lesion. 
Disturbances of general sensation comprise disorders in the sense 
of touch, pressure sense, the senses of temperature and pain, and 
of muscular sense, which comprises the perception of active and 
passive movements. Disturbances of special sense are treated in 
the section dealing with the several cranial nerves. 

Tactile Sensation. — The acuity of tactile sensibility is tested 
by gently touching the cutaneous surface in various regions with 
a feather, a camel's-hair brush, or with a twisted wick of cotton, 
while the subject's eyes are bandaged. Tactile sensation is also 
investigated by detecting the minimal distances at which the two 
points of a compass may be appreciated when simultaneously 
placed upon the skin of the subject. 

The normal subject can state the precise instant at which the 
integument is touched and, in a general way, the nature of the 
fabric with which it is in contact. The readiness with which the 
two compass points are recognized varies widely in different 

663 



664: PHYSICAL DIAGNOSIS 

regions of the body, being most sensitive upon the tip of the 
tongue, where they are recognized when separated by only one 
millimeter, and least readily detected upon the back, arm, and 
thigh, where they are only recognized when separated by a space 
of from 60 to 80 millimeters. While the readiness with which 
tactile sensations are registered is a reliable index to the integ- 
rity of the sensory pathwa}^, allowance must be made in certain 
instances of delayed transmission for the degree of natural intel- 
ligence of the subject of the examination. 

Moderate impairment of tactile sensibility constitutes hypes- 
thesia, indicating in the majority of cases a compression or 
partial lesion of the sensory pathway. An abnormally acute per- 
ception of tactile sensation constitutes hyperesthesia, which fre- 
quently indicates a functional irritability of the sensory pathway. 
A complete abolition of tactile sensibility over a zone of the body 
constitutes anesthesia. A circumscribed anesthesia is likely to 
prove of peripheral origin, whereas an extensive zone, embracing 
one-half of the body or the entire body below a definite level is 
of central origin. 

In the presence of a complete transverse lesion of the spinal 
cord there is anesthesia and motor palsy which is bilateral below 
the level of the lesion. In the presence of a hemisection of the 
cord or of a lesion involving only one lateral half of the cord, 
there ensues the phenomenon which is designated Brown-Sequard 
paralysis, in which there is complete motor palsy upon the corre- 
sponding side below the level of the lesion, with complete anes- 
thesia and partial loss of motor power upon the side opposite to 
the cord lesion. 

Pressure Sense. — The pressure sense is investigated by noting 
the ability of the subject to appreciate minor variations in pres- 
sure, when cubes of uniform size but of varying weight are placed 
upon the surface under examination. During this examination 
muscular sensation is to be eliminated by placing the limb upon a 
firm, unyielding surface ; and temperature sense must be excluded, 
as extremes of temperature have a tendency to impair the nicety 
of the pressure sense perception. Variations in pressure sense, 
which possess the same significance as do similar variations in 
tactile sensation, are not relied upon as much as are the latter in 
neurologic examinations. 

Sense of Temperature. — The entire cutaneous surface is sup- 
plied with specific ''heat spots" and ''cold spots," which are 
supplied by nerve endings for the appreciation of these extremes 



SENSORY PHENOMENA — THE REFLEXES 665 

of temperature sense. Hence the power of discriminating varia- 
tions in temperature may be retained, while tactile sensation is 
temporarily or permanently abolished. Compression of the ulnar 
nerve, which causes a marked diminution of tactile sensibility 
over the distribution of the nerve, does not involve the tempera- 
ture perception in this area. As a general rule, the portions of 
the body which are habitually clothed are more sensitive to 
thermic variations than are the exposed portions of the integu- 
ment. 

The cutaneous perception of temperature is most conveniently 
tested by the application to the area under examination alter- 
nately of test tubes containing water at temperatures consider- 
ably above and below the body temperature. In the presence of 
organic disease of the spinal cord, as syringomyelia and in the 
presence of lesions of the medulla and pons, as hemorrhage, 
tumor, or softening, the perception of temperature is impaired 
(thermohypesthesia). Similarly destructive lesions in these 
regions result in total abolition of the perception of changes of 
temperature, constituting thermoanesthesia; whereas functional 
irritability of the tract of Gowers may result in an exaggerated 
perception of variations in temperature, constituting thermo- 
hyperesthesia. 

Sense of Pain. — While it is true that any form of appreciable 
sensation when sufficiently magnified and intensified may assume 
such proportions as to render its perception painful, it is yet 
generally agreed that there are specialized ''pain spots" dis- 
tributed universally over the cutaneous surface, which are sup- 
plied by special nerve endings; and that the sensation of pain 
when pronounced is not invariably due to overstimulation of the 
fibers having to do with tactile or temperature sensation, but to 
hyperstimulation of these specific pain centers in the integument. 

The perception of the sense of pain is investigated b}^ pricking 
the integument of the area under examination with a sharpened 
quill or with an ordinary pin or needle. In the presence of cen- 
tral cord lesions which are incomplete, in dorsal sclerosis of the 
cord and in lesions of peripheral nerves, the perception of pain- 
ful stimuli may be delayed and impaired, constituting hypalgesia, 
or may be totally abolished in the area under investigation, con- 
stituting analgesia. Similarly in the presence of functional 
nervous states the examiner is apt to encounter an exaggerated 
perception of painful stimuli, constituting in this event hyper- 
algesia. 



666 PHYSICAL DIAGNOSIS 

Different forms of perverted sensatio^i may be encountered, 
which are grouped under the term parasthesiae. These perver- 
sions are principally subjective in character and are not modified 
or influenced by objective examination of the subject. They may 
assume the character of the crawling of insects (formication); 
they may take the form of alternate flashes of heat and of cold; or 
the subject may complain of transient numbness. Occasionally 
upon painful stimulation of one extremity there is experienced 
coincidentally a painful sensation in a symmetrical distribution 
of the opposite limb, constituting in this instance, allocheiria. 

Muscular Sense. — Muscular sensation is the peculiar sense by 
means of which judgments are formed as to the weight of articles 
which are lifted, by which the patient is aware of the position of 
certain portions of the body without the aid of the eyes, and by 
which he is enabled to maintain the standing posture without 
conscious effort. 

The muscular sense may be examined by directing the subject, 
with the eyes lightly bandaged, to place the finger upon a certain 
designated portion of the body, as for instance, the tip of the 
nose; it is also tested by directing the patient to stand upright 
with the feet closely approximated and with closed eyes. Thus, 
in organic disease of the nervous system the disturbance of the 
muscular sense, with coincident tactile sensory disturbance, is 
responsible for Romberg's sign. 

The muscular sense is also investigated by noting the percep- 
tion of active and passive movements of the limbs. Thus, the 
subject is directed to perform various movements with the limbs, 
such as describing a semicircle on the floor with the toe, or touch- 
ing the knee with the ankle of the opposite limb. In testing the 
perception of passive movements, the limb of the patient is 
slowly moved, while the eyes are lightly bandaged, and he is 
asked to indicate by pointing the range of movement and the 
new position of the limb. 

Stereognostic Sense. — Stereognostic sensibility is the faculty 
by which objects placed in the hand are recognized by their pal- 
pable shape and consistence. An abolition of this sense (astereog- 
nosis) is frequently indicative of a lesion involving the superior 
parietal lobule of the brain. 

Reflexes. — The Reflex Arc. — The simplest form of reflex arc 
comprises an afferent or sensory neurone, which conducts impulses 
from the periphery of the body to an intermediate cell station 
situated in the gray matter of the spinal cord, and an efferent 



SENSORY PHENOMENA THE REFLEXES 667 

motor nenroue, over wliicli the intermediate cell station or medul- 
lary center discharges impulses in response to the sensory stimulus 
which is conveyed to it by way of the afferent sensory neurone. 
The entire sequence of changes which ensues upon adequate stimu- 
lation of the receptor of the afferent sensory neurone constitutes 
the reflex act. 

In the case of the spinal reflexes the afferent neurone is repre- 
sented by the peripheral spinal sensory nerve with its root ganglion, 
the intermediate cell station by the cells of the gray matter of the 
spinal cord, and the efferent neurone by the motor nerve arising 
from the cells of the anterior horn of the cord. The shorter branch 
of the dorsal nerve root upon entering the posterior horn of the 
spinal cord gives off collaterals which pass immediately to form 
synapses with the cells of the anterior horns of the same side of the 
spinal cord, a reaction in this instance constituting a homolateral 
spinal reflex. However, the spinal nerve root also furnishes col- 




Fig. 302. — Percussion hammer. 

lateral branches which pass by way of the anterior white commis- 
sure to form synapses with the anterior cornual cells of the opposite 
side of the cord, resulting in contralateral reflexes. Also certain col- 
lateral branches form synapses with motor cells in higher and lower 
levels of the spinal cord. A much more complicated reflex is repre- 
sented by the collaterals which establish connections with the cells 
of origin of the columns of Goll and Burdach, by which they are 
relaj^ed to the gracile and cuneate nuclei of the medulla, thence by 
the arcuate fibers to the opposite optic thalamus, and thence by the 
third sensory neurone to the sensory area of the cerebral cortex. 
In this situation an intermediate cell station in the form of associa- 
tion bundles is established, the efferent motor neurone of this ex- 
tensive reflex arc being represented by the pyramidal tracts, the 
reflex action resulting in consciousness and in volitional muscular 
movement. Another very complex reflex arc is formed by the 
dorsal root fibers which form synapses with the cells of Clarke's 
column, whence the impulse is relayed by the ascending spino- 



668 PHYSICAL DIAGNOSIS 

cerebellar tract of Flechsig to the cerelTellar cortex and dentate 
nucleus, thence to the red nucleus of the midbrain, and thence 
by the rubrospinal tract to the anterior cornual cells, the reflex 
act in this instance having for its expression the regulation of 
muscle tone and the synergic action of different muscles in the 
maintenance of equilibrium. 

Simple spinal reflexes occur without any intervention upon the 
part of the cerebrum, the various spinal segments acting inde- 
pendently ; but there are governing fibers descending in the pyram- 
idal tracts from the cerebral cortex, which ^modify and may 
volitionally inhibit the spinal reflexes. 

Reflexes are variously classified as tonic and clonic, as super- 
ficial reflexes and as deep reflexes. The principal superficial 
reflexes are the plantar, cremasteric, and abdominal reflexes; 
while the principal deep reflexes comprise the patellar and achilles 
tendon reflexes, the jaw-jerk, the ankle clonus and the patellar 
clonus. 

Abdominal Reflex. — The abdominal reflex consists in a contrac- 
tion of the underlying rectus muscle when the integument is 
stimulated, as for instance, by gently scratching with a sharp 
instrument. This reflex should be elicited upon either side of the 
abdomen both above and below the level of the umbilicus, in 
order to demonstrate the independence of the upper portion of 
the rectus, which is supplied by the eighth and ninth intercostal 
nerves ; and the lower portion of the rectus, which is supplied by 
the tenth and eleventh intercostal nerves. In each case, the um- 
bilicus is observed to be drawn toward the side of the stimulation 
in the presence of an intact reflex. It may readily be demon- 
strated that in the case of the normal subject the umbilicus is 
not displaced upon changing from the dorsal recumbent to the 
sitting posture. But in the presence of paralysis of the lower 
portion of the rectus, upon the change of posture the umbilicus 
is elevated, thus differentiating the lesion of the tenth and eleventh 
intercostals from the integrity of the eighth and ninth intercostal 
nerves above the umbilicus. 

Cremasteric Reflex. — Upon stimulation of the integument upon 
the inner side of the thigh the testicle of the corresponding side 
is elevated. The segments which preside over the cremasteric 
reflex comprise the first and second lumbar segments. 

Plantar Reflex. — In the normal subject, when the sole of the 
foot is stroked with a probe or a sharp instrument, plantar 
flexion of all of the toes ensues as the reflex response. In the pres- 



SENSORY PHENOMENA THE REFLEXES 



669 



ence of a lesion of the upper motor neurone, instead of the uni- 
form plantar flexion of the toes, the great toe is extended while 
the remaining toes are flexed (Babinski's sign). In eliciting the 
plantar reflex the outer portion of the sole should be stroked in 
a direction from before, backward toward the heel. Subjects 
yielding Babinski's sign usually also yield upon proper stimu- 
lation the reflexes of Oppenheim and of Gordon. 

Oppenheim's Reflex. — Oppenheim 's reflex is elicited by passing 
the thumb or the handle of the percussion hammer downward 
along the internal border of the tibia, at the same time exerting 
pressure upon the soft tissues, whereupon extension of the great 
toe with plantar flexion of the remaining digits ensues. The sig- 




Fig. 303. — !Elicitation of Babinski's sign. 



nificance of Oppenheim's reflex is entirely identical with that of 
the pathologic plantar reflex. 

Gordon's Reflex. — If, instead of proceeding as in the case of 
Oppenheim's reflex, the examiner merely grasps the muscles of 
the calf of the leg and exerts deep pressure, in the presence of a 
lesion of the upper motor neurone, extension of the great toe 
ensues. 

The Patellar Tendon Reflex (Knee-jerk). — If the patient is in 
the sitting posture, to elicit the knee-jerk the leg is flexed upon 
the thigh at a right angle, while the patellar tendon is struck 
a rapid light blow with the percussion hammer. If the patient is 
bedridden, the reflex may be elicited by raising the leg from the 



670 



PHYSICAL DIAGNOSIS 



bed by means of a hand placed beneath' the knee joint while the 
blow is delivered. 

During the examination every effort should be made to distract 
the attention of the patient from the procedure in order to pre- 
vent cerebral inhibition of a normal reflex. If the subject is very 
selfconscious and the reflex consequently is elicited with diffi- 
culty, Jendrassik's reinforcement may be resorted to. The pa- 
tient is directed to lock the hands and to pull, meanwhile keeping 
his eyes fixed upon the ceiling. The reflex arc of the patellar 
tendon reflex comprises the second, third, and fourth lumbar 
segments. 




Fig. 304. — iClicitatioii of patellar tendon retiex. 



Exaggeration of the patellar tendon reflex is indicative of disease 
between the level of the reflex arc and the cerebral cortex, 
whereby the governing impulses from the cerebrum are inter- 
rupted. Such a condition arises in spastic spinal paraplegia, 
amyotrophic lateral sclerosis, cerebral hemorrhage, and dissemi- 
nated sclerosis. 

Abolition of the patellar tendon reflex is. indicative of a break 
in the reflex arc due to disease of the sensory neurone, posterior 
root zone, or anterior root cells. Such lesions arise during the 



SENSORY PHENOMENA THE REFLEXES 



671 



progress of tabes dorsalis, anterior poliomyelitis, peripheral neu- 
ritis, and trauma to the cord at the level of the reflex arc. 

The Tendo Achillis Reflex. — This reflex may be elicited by 
directing the patient to kneel upon a chair, and, rendering the 
tendon taut by moderate dorsal flexion of the foot, the tendo Achillis 
is struck sharply, whereupon normally a sudden extension of the 
foot is produced. The reflex arc concerned in this reflex comprises 
the first and second sacral segments; and the significance of varia- 
tions in the response is identical with those detailed under the 
knee-jerk. 

The Jaw- Jerk. — In the presence of amyotrophic lateral sclerosis 




Fig. 305. — EHcitation of ankle clonus. 

upon striking the point of the chin with the percussion hammer 
w^hile the mouth is half opened the jaw-jerk is elicited. This 
reflex is distinctly pathologic and is not present in the normal 
subject. The reflex arc is represented by branches of the tri- 
geminal nerve. 

Ankle Clonus. — In eliciting this clonus the examiner grasps the 
calf of the leg in the palm of the left hand, while Avith his right 
hand he exerts pressure upon the fore part of the sole of the foot, 
thus maintaining the foot in a position of dorsal flexion. In the 
presence of disease of the upper motor neurone, as in dissemi- 
nated sclerosis, cerebral hemorrhage, or spastic |)araplegia, a 
series of regularly rhythmical contractions of the calf muscles 



672 PHYSICAL DIAGNOSIS 

ensue, which continue until the muscles are temporarily ex- 
hausted. The reflex arc in this instance is represented by the first, 
second, and third sacral segments. 

Patellar Clonus. — The patellar clonus is elicited by placing the 
limb in a position of full extension and grasping the patella be- 
tween the thumb and fingers and exerting strong downward 
pressure upon the quadriceps extensor tendon. In disease of the 
upper motor neurone a series of rhythmical contractions are set 
up in the quadriceps extensor analogous to that which is obtained 
in the case of the ankle clonus. The reflex arc in this instance 
is constituted by the second, third, and fourth lumbar segments 
of the spinal cord. 



CHAPTER XXXIV 
THE CRANIAL NERVES 

The twelve cranial nerves are paired nerves, resembling in this 
respect the spinal nerves. The first two cranial nerves, however, 
the olfactory and optic, differ so markedly in their anatomic and 
physiologic features from the other cranial nerves as to have been 
compared to accessory lobes of the brain. The centers of the cranial 
nerves lie in a mass of gray matter along the floor of the fourth 
ventricle, the aqueduct of Sylvius and the floor of the third ven- 
tricle, representing an upward continuation of the central gray 
matter of the spinal cord. 

Lesions involving the cranial nerves may be situated in the 
cerebral cortex or the fibers descending from the cortical cells 
to the deep origin of the cranial nerves (supranuclear lesions), 
may involve the nucleus alone (nuclear lesions), or may involve 
only the peripheral portion of the nerve (infranuclear lesions). 
While supranuclear and infranuclear lesions not infrequently 
manifest themselves in derangements of a single cranial nerve, 
the nuclei of origin of these nerves are so closely aggregated be- 
neath the floor of the fourth ventricle and sylvian aqueduct that 
a lesion in this situation usually involves the nuclei of several 
cranial nerves, with the consequent production of more general 
manifestations. 

THE OLFACTORY NERVE 

The center for the olfactory nerve is probably situated in the 
uncinate and hippocampal gyri, with communicating fibers to the 
cerebral cortex, optic thalamus, and internal capsule. The ter- 
minal branches of distribution of the nerve are distributed to tiie 
superior turbinated bodies and the upper portion of the septum, 
w^hence they pass upward to the dilated anterior extremities of 
the olfactory tracts, the olfactory bulbs. 

The integrity of the olfactory nerve is tested Avith familiar 
odorous substances, such as the oils of peppermint or cloves, co- 
logne water or cinnamon. Ammonia or acetic acid should not be 
employed, as they are known to affect the trigeminal nerve. In 

673 



674 PHYSICAL DIAGNOSIS 

applying the test the substance is applied* to each nostril sepa- 
rately and in turn, Avith the eyes of the subject meanwhile closed. 

The sensibility of the nerve may be diminished or abolished 
by local or central conditions. The most frequent cause for loss 
of the sensibility of the nerve lies in local nasal conditions, as 
coryza or polypi. In the aged there is often a normal diminution 
in the acuity of the perception and differentiation of odors. More- 
over, after prolonged or excessive stimulation the sense of smell 
becomes blunted or diminished for the time being. 

Marked diminution in the acuity or abolition of the olfactory 
sense, anosmia, is significant of many intracranial conditions. In 
congenital absence of the olfactory nerves it is a natural se- 
quence. Compression of the nerve trunk by aneurysm of the mid- 
dle cerebral artery, by chronic hydrocephalus, by a cerebral tumor 
or abscess, or irritation by a meningitis chiefly localized to the 
anterior fossa of the skull results in anosmia. Destructive lesions 
of the bulb or tract, caries of the cranial bones, or injury incurred 
during basal fracture, cause anosmia. Similar loss of the olfac- 
tory sense is noted in tabes dorsalis and paresis. 

Perversions of the olfactory sense, parosmia, are not infrequently 
met with in cases of tabes dorsalis, during the auras of epileptic 
seizures, and in various mental disorders. 

Hyperacuity of the sensibility of the nerves, hyperosmia, occurs 
in neurotic and insane patients. The acuity of this special sense is 
often markedly increased in persons following certain occupations 
and in blind patients. 

THE OPTIC NERVE 

The optic nerve and retina have been aptly called an accessory 
lobe of the brain. The visual fibers of the optic nerve take origin 
from centers upon the mesial aspect of the occipital lobe of the 
cerebrum in the region of the calcarine fissure and the cuneus 
on either side. These are the higher centers of vision. From 
these centers the right and left optic radiations respectively pass 
forward and form synapses with fibers terminating in the ex- 
ternal geniculate bodies and the corpora quadrigemina of the two 
sides of the brain. From these centers fibers arise which form the 
optic tract, a band of fibers Avhich courses around the crura cere- 
bri on either side to meet anteriorly and form the optic chiasm, 
where a partial decussation of the fibers occurs, the right optic 
tract distributing visual fibers to the right half of each retina, 



THE CRANIAL NERVES 675 

and the left tract supplying similar fibers to the left half of each 
retina. Lesions involving different portions of these tracts pro- 
duce characteristic lesions which aid in localizing the individual 
lesion. 

The light fibers, the fibers of the optic nerve and retina which 
react to light stimuli, arise in the retina, whence they pass back- 
ward in the optic nerve, undergoing partial decussation at the 
chiasm, and proceed along the optic tracts to the external genicu- 
late bodies and corpora quadrigemina, whence they pass to the 
oculomotor nucleus beneath the floor of the aqueduct of Sylvius 
by way of the fasciculus sublongitudinalis. Thus the reflex arc of 
the light reflex is composed of an afferent limb, a substation in the 
midbrain, and an efferent limb, which will be considered in detail 
under the examination of the third cranial nerve. 

Vision. — The acuity of vision normally is tested with the ordi- 
nary Snellen Test Type. 

Amhlyopia. — Amblyopia, dimness of vision, which is not due to 
errors of refraction, may result from the excessive use of tobacco 
or alcohol. Amblyopia may also arise during diabetes mellitus, or 
it may signify impending uremia in a nephritic patient. The in- 
gestion of certain drugs, as quinine or the salicylates, may induce 
amblyopia. 

HemeraJopia (Daij-Blindness). — Hemeralopia, a condition in 
which the vision is impaired during the day, but improves on dark 
days or at night, is often part and parcel of tobacco amblyopia. 
It may also signify chronic optic neuritis from intracranial causes 
or intoxications, or chronic retinitis from a similar cause. 

Nyctalopia (Night-Blindness) . — Nyctalopia, characterized by im- 
perfect vision in subdued light, is often the result of frequently re- 
peated exposures to strong illumination. In other instances it is a 
congenital defect of the visual apparatus. 

Color Vision (Color-Blindness).— The inability to differentiate 
between differences in the gradation of colored fabrics is in most 
instances an inherited defect. Acquired color-blindness occurs, 
however, as the result of toxic amblyopia, optic neuritis, or as a 
rare result of trauma to the cranium. In testing for color-blind- 
ness, the Holmgren or Thomson test should be employed. 

Holmgren Test. — In applying this test the patient is given a 
skein of wool of a light-pink color and directed to select from a 
mass of similar skeins of various colors and shades of colors all 
those which nearly match the color of the selected test skein. 



676 PHYSICAL DIAGNOSIS 

■ * 

If the color vision is impaired, skeins of varying colors, gray, 
green, pink, and brown, will be selected indiscriminately. If the 
subject fails on the pink skein, a pure green skein is selected for 
a control. 

Thomson's Test. — In this test a stick to which numerous bundles 
of yarn of various colors are attached is employed. The colors 
have corresponding numbers, the odd numbers being green and 
the even numbers corresponding to the confusing colors. The 
color vision is tested with a pale green test skein, the patient being 
required to match it with ten tints on the rod. The selection of 
skeins with even numbers reveals the patient's inability to dis- 
criminate between the different shades and colors. A control 
test should be made with red and old-rose skeins as test colors. 

Field of Vision. — The dimensions of the field of vision in each 
eye is best determined by a perimeter; but as this instrument is 
usually not available, other methods of testing the field of vision 
must be employed. A rough but sufficiently accurate estimation 
of the size of the field of vision may be made by the following 
simple procedure. 

The patient is seated in a straight chair with his back toward 
the source of illumination, the examiner occupying a chair facing 
the patient, and approximately three feet from him. In testing 
the left eye, the right eye of the patient is covered with a bandage; 
the examiner closes his right eye, at the same time fixing his left 
eye upon the pupil of the left eye of the patient. The examiner, 
beginning well beyond the limits of vision for both patient and 
himself, slowly moves his hand inward until the patient first 
sees the finger-tips. This maneuver is repeated in all the meridians 
of the visual field; and if the finger-tips become visible to the 
patient at the same instant they are apprehended by an examiner 
with a normal visual field, the patient's visual field is of normal 
extent; that is, is not contracted. If, on the contrary, the 
hand of the examiner must be brought nearer the visual axis than 
is required for the normal examiner, the visual field of the patient 
is contracted. 

Contractions of the visual field may be concentric or irregular. 
Concentric contraction is noted in many cases of hysteria, and also 
in glaucoma. Irregular or asymmetric contractions, represented 
by scotomata and hemianopia possess a varied significance. 

Scotomata are to be detected by passing small pieces of white 
and colored cardboard across the axis of vision while the patient 



THE CRANIAL NERVES 677 

fixes the eye under examination upon a designated objective point. 
Under these circumstances the patient is directed to state the 
point in the progress of the cardboard at which it becomes tem- 
porarily invisible. It is to be remembered that there is a physio- 
logic scotoma for light and color, corresponding to the blind 
spot of Mariotte, which must be eliminated in ocular examinations. 
An absolute scotoma, betrayed by the inability of the patient to 
recognize in the scotomatous field a white cardboard or light stimuli, 
is significant of grave destructive lesions, as optic neuritis or a 
lesion involving some portion of the optic tract. A relative or color 
scotoma, revealed by the inability of the subject to appreciate red 
and green cards in certain portions of the visual field, is usually 
the result of the excessive use of tobacco or alcohol, and gives a 
distinctly better prognosis than do the absolute scotomata. 

Hemianopia, obliteration or darkening of one-half of the visual 
field, is tested for clinically by the maneuver used for determin- 
ing variations in the extent of the visual field ; which, in the pres- 
ence of hemianopia reveals a darkening of one-half of the visual 
field. 

Hemianopia may be horizontal or vertical, homonymous or 
heteronymous, bitemporal, binasal or mixed, as the case may 
prove. 

The significance of hemianopia is a lesion involving the optic 
nerves, optic chiasm, or optic tract; and the site of the intra- 
cranial lesion is determined by the distribution of the hemianopic 
changes. In homonymous hemianopia the corresponding halves 
of the visual fields are obliterated ; as, for instance, the temporal 
half of the right retina and the nasal half of the left retina. 
Such an ocular finding constitutes left lateral homonymous 
hemianopia, the significance of which is a lesion involving the 
right optic tract alone. Similarly a bitemporal hemianopia sig- 
nifies a lesion involving the central portion of the chiasm, whereas 
a binasal hemianopia is produced by lesions at both extremities 
of the chiasm, but sparing the central portion of this structure, a 
condition which rarely occurs. Transitory hemianopia sometimes 
occurs with hysteria and migraine without anatomic change in 
the tract. 

Wernicke's Pupillary Reaction. — If, in a case of hemianopia, 
with the patient seated in a darkened room, a thin ray of light 
from an ophthalmoscopic mirror is projected into the orbit upon 
the hemianopic retinal area at an angle of 40 to 60 degrees from 
the visual axis, myosis may or may not result. In hemianopias 



678 PHYSICAL DIAGNOSIS 

in which the causative lesion is situated in the optic tract anterior 
to the corpora quadrigemina no pupillary reaction will occur, as 
the reflex arc for the light reflex is broken; but if the lesion is 
situated posterior to the corpora quadrigemina, the myosis occurs, 
as the reflex arc in this instance is not disturbed. This test, de- 
pending partially on the action of the third cranial nerve, is em- 
ployed to further localize lesions productive of hemianopia. 

THE THIRD, FOURTH, AND SIXTH CRANIAL NERVES 

These nerves, which control the pupillary reactions, and the 
movements of the ocular muscles, are more profitably examined 
in unison than singly and individually. All three nerves arise 
from nuclei situated beneath the floor of the fourth ventricle 
and the aqueduct of Sylvius. The third cranial nerve (oculomo- 
tor) supplies fibers to the sphincter of the pupil and all of the 
ocular muscles except the external rectus and the superior oblique. 
The fourth cranial nerve (trochlear) supplies the superior oblique 
muscle of the eye. The sixth cranial nerve (abducent) supplies 
the external rectus muscle of the eye. 

Pupillary Reflexes. — LigJit Reflex. — The normal pupil when 
exposed suddenly to light stimuli responds by a reflex contraction 
of the iris. The light reflex may be elicited by shading the eyes 
with the hands whereupon, on suddenly uncovering one eye the 
pupillary contraction may be noted. This method of examination, 
however, is apt to prove fallacious, inasmuch as a reaction to ac- 
commodation is likely to be mistaken for a normal light reflex. 
This source of error may be avoided by throwing a beam of light 
from an ophthalmoscopic mirror upon the shaded eye, or by test- 
ing similarly with the illumination from a small electric flash- 
light. In the absence of these instruments, the reflex may be 
elicited by exposing the pupil to the light of a burning match. 

The- reflex arc involved in the light reflex consists of an af- 
ferent limb consisting of the optic nerve and tract, the corpora 
quadrigemina and fasciculus sublongitudinalis, a station repre- 
sented by the third nerve nucleus, and an efferent limb com- 
prising the third cranial nerve, the ciliary ganglion and ciliary 
nerves to the sphincter pupillae. 

A sluggish reaction to light or total abolition of the light re- 
flex signifies optic atrophy, partial or complete paralysis of the 
third cranial nerve, or degenerative changes in the ciliary gan- 
glion. It may signify compression of the optic tract, or the fas- 



THE CRANIAL NERVES 679 

ciculus sublongitudinalis, Avhich forms the connecting link be- 
tween the corpora quadrigemina and the third nerve nucleus. 

Consensual Light Reflex. — If during the examination for the 
light reflex in one pupil, the pupil of the opposite eye is observed, 
while shaded and protected from the light stimuli applied to 
the opposite retina, it will be observed to react along with the 
pupil of the exposed eye. This phenomenon constitutes the con- 
sensual light reflex, and is due to the transmission of an im- 
pulse across the flbers which connect the two third nerve nuclei. 

Beactioji to Accommodation. — ^When the range of vision is 
suddenly transferred from a distant objective point to an object 
near at hand, the pupils will be observed to contract and the 
eyes to converge, the reaction to accommodation. This reaction 
may be quickly tested by directing the patient to flx the gaze 
on a distant portion of the room, and then quickly to transfer 
the gaze to the finger of the examiner held near the face of the 
patient. Abolition of this reflex is due to third nerve paralysis. 

Argyll-Robertson Pupil. — Abolition of the light reflex in one 
or both eyes with retention of the reaction to accommodation 
constitutes the Argyll-Robertson pupil, which is occasionally 
found in disseminated sclerosis, and very frequently in tabes 
dorsalis and paresis. Marina has shoAvn this type of pupillary 
reaction to be caused by degenerative changes in the ciliary 
ganglion. In this pupil the pupillary margins are very fre- 
quently irregular, while the pupils are often somewhat myopic 
(spinal myosis) from disease of the cervical cord. Ultimately 
in tabes and paresis the pupil becomes immovably fixed, re- 
acting neither to light nor to accommodation. 

An opposite pupillary reaction, the pupil reacting to light, 
but failing to react to accommodation is often seen as a sequence 
of postdiphtheritic paralysis. 

Hippus. — Rapid, rhythmic, clonic contractions of the sphincter 
pupillge producing winking movements of the iris which are so 
gross as to be visible to the unaided eye (hippus) are frequently 
demonstrable in disseminated sclerosis, more rarely in hysteria, 
incipient acute meningitis, and epilepsy. 

Pupillary Unrest. — This phenomenon, which is a normal phys- 
ical finding, consisting of a regular narroAving and widening of 
the pupil, is so fine that it can only be demonstrated by means 
of the aid of a magnifying lens with the pupil brilliantly illumi- 
nated. Abolition of this normal pupillary unrest is one of the 
earliest signs of tabes dorsalis and paresis. 



680 PHYSICAL DIAGNOSIS 

Myosis. — Contraction of the pupil may Result from irritative 
or destructive lesions. Irritative myosis is noted in the early 
stages of cerebral hemorrhage, in incipient brain tumors before 
sufficient pressure has been exerted upon the third nerve to 
cause paralysis, and in early acute meningitis and encephalitis. 
Paralytic myosis is seen in tabes dorsalis, the late stages of tabes 
of the cervical cord, and syringomyelia of this portion of the cord, 
leading to destruction of the pupil-dilating fibers. 

Mydriasis. — Irritative mydriasis is often due to irritation of 
the pupil-dilating center in the cervical cord from congestion, 
spinal meningitis, or tumor. Paralytic mydriasis may signify 
paralysis of the sphincter pupilla, caused by disease of the third 
cranial nerve or ciliary ganglion, increased intracranial pressure 
from brain tumor, or glaucoma. 

Strabismus (Squint). — In paralysis of one or more ocular 
muscles the normal axis of the eyeball deviates from its normal 
position, with the production of double vision or diplopia. A 
simple rule in the differentiation of the various ocular paralyses 
is that the affected eye is displaced by the unopposed antagonists 
to the side opposite to the usual traction of the paralyzed mus- 
cle, while the false image, the result of diplopia, is displaced in 
the direction of the line of traction of the paralyzed muscle (Pur- 
ves Stewart). 

Nystagmus. — Nystagmus is a rapid oscillation of the globe of 
the eye upon voluntary motion, usually in a horizontal direction, 
more rarely in a vertical direction, and very rarely it is rotary. 
It is a sign of value in disseminated sclerosis, epilepsy, chorea, 
brain tumor, tabes dorsalis, Friedreich's ataxia, and in some cases 
of chorea. Nystagmus may be the result of errors of refraction 
and may be noted in albinos. Miners are subject to a form of 
nystagmus, probably caused by the constant excursion of the 
eyes while working in the recumbent or stooping posture. 

Aural nystagmus, which may be produced experimentally by 
syringing the membrana tympani with water either above or 
below the temperature of the body, is regarded by Barany as 
the result of convection currents produced in the endolymph 
by the warming and cooling of the labyrinth. This ''thermic nys- 
tagmus " is of value in testing the integrity of the vestibular nerve. 

Conjugate Deviation. — This comprises a concomitant deviation 
of both eyes toward the right or left, its significance being a lesion 
in the cerebral cortex, corona radiata, or internal capsule, above 
the crossing of the motor fibers. Thus, in cerebral hemorrhage 



THE CRANIAL NERVES 681 

the eyes are turned toward the side of the lesion and opposite 
to the side of the paralysis (Prevost's sign). In interpreting the 
sign it is to be remembered that the lateral movements of the eyes 
are governed by impulses arising in the cerebral cortex and passing 
by Avay of the corona radiata and internal capsule to the sixth 
nerve nucleus of the corresponding side, and thence across the 
posterior longitudinal fasciculus to the subdivision of the opposite 
oculomotor nerve nucleus which presides over the internal rectus 
muscle. Thus the conjugate lateral deviation of the eyes is caused 
by the simultaneous stimulation of the external rectus muscle 
on the side of the lesion and of the internal rectus muscle on 
the side opposite to the lesion, causing the patient to ''look at 
his lesion." 

Ptosis. — Ptosis of the upper eyelid is revealed by the inability 
of the patient to elevate the lid. It is due to a lesion of the 
oculomotor nerve or nucleus. Isolated paralysis of the fourth 
cranial nerve is very rarely encountered, as this nerve usually 
participates in the palsies of the third and sixth nerves. In the 
rare instances of simple trochlear paralysis there is inability to 
rotate the globe downward and outward. Cerebral syphilis is the 
usual cause of the paralysis. 

Abducent Paralysis. — Isolated paralysis of the sixth cranial or 
abducent nerve is revealed by the inability of the patient to 
rotate the eyeball outward beyond the midpoint. Upon en- 
deavoring to follow the finger of the examiner the external rota- 
tion of the globe is interrupted at this point. 



TRIGEMINAL NERVE 

The trigeminal nerve has an extensive origin from the floor of 
the fourth ventricle, beneath the aqueductus sylvii, and the cer- 
vical spinal cord as low as the second cervical nerve. The fifth 
cranial is a mixed nerve, containing both motor and sensory 
fibers. The fibers constituting the sensory trunk have developed 
upon them the Gasserian ganglion which rests in a small fossa 
upon the petrous portion of the temporal bone. The motor root 
of the nerve supplies the masseters, the temporals, pterygoids, 
internal and external, mylohyoid, anterior belly of the digastric, 
the levator and tensor palati and tympani; and the azygos uvulse. 
The sensory trunk and Gasserian ganglion terminate in three 
trunks, the superior and inferior maxillary, and the ophthalmic, 
which distribute sensory fibers to the anterior tAvo-thirds of the 



682 PHYSICAL DIAGNOSIS 

tongue, the mucous membrane of the buccal and nasal cavities, 
the salivary glands and teeth, the infraorbital and mandibular 
portions of the face, and the anterior portion of the scalp. 

Motor Paralysis. — Motor paralysis of the fifth cranial nerve is 
tested for by palpating the masseter and temporal muscles while 
the patient is directed to clench the teeth. In unilateral paraly- 
sis there is loss of the prominence with which the muscles stand 
out on the normal side. The patient is then directed to open the 
mouth and protrude the lower jaw. In unilateral paralysis the 
jaw is deviated toward the paralyzed side by the action of the 
sound external pterygoid muscle. 

Irritative lesions of the motor trunk or centers produces tris- 
mus, a mild form of tetanic spasm of the muscles of the lower 
jaw. Severe tetanic spasm of these muscles accompanies tetanus 
and strychnine poisoning. 

Sensory Paralysis. — Sensory paralysis involving the inferior 
maxillary division of the nerve produces anesthesia of the in- 
fraorbital region, which is tested for by drawing lightly across 
the face a small pledget of cotton loosely rolled or a camel's 
hair brush. 

Implication of the sensory fibers and the Gasserian ganglion 
are recognized by the very painful spasm, tic douloureux. 

In testing the sense of taste over the anterior two-thirds of 
the tongue the patient is directed to protrude the tongue and the 
examiner places on it various substances, such as quinine, sugar, 
salt, and citric acid, in powdered form. While the tongue is 
protruded the patient is required to point out on a printed card 
whether the sensation appreciated is sweet, sour, bitter, salty, or 
negative. The patient should not be allowed to make his decision 
after the tongue has been returned to the oral cavity as the flavors 
may be carried by the saliva to the posterior portion of the 
tongue which is supplied by the glossopharyngeal nerve. 

THE FACIAL NERVE 

The nucleus, or origin, of the facial nerve lies in the lower por- 
tion of the pons near the medullary junction, the root fibers of the 
nerve emerging at the lower border of the pons just internal to 
the point of emergence of the auditory nerve. In company with 
the auditory nerve, the facial nerve enters the internal auditory 
meatus of the temporal bone, transverses the aqueductus fallopii 
of that bone, and emerges from the stylomastoid foramen. In 



THE CRANIAL NERVES 



683 



the aquecluctns fallopii the nerve receives the chorda tympani, 
which contains taste fibers from the anterior portion of the tongue. 
After emerging from the stylomastoid foramen the nerve divides 




Fig. 306. — Facial paralysis. 



I 


• - 


3 


i 


» 


1 


4 


^■C'"* ». 

..:" _.... ^m.. 


je^'M^ ^m^H 



Fig. 307. — Facial paralysis. (Church.) /, bilateral attempt to raise eyebrows; 2, bilateral 
attempt to close eyes; i, smiling. (From Eisendrath.) 

into a number of diverging branches to supply the majority of 
the muscles of the head and face. 

Facial Paralysis. — The facial nerve is purely a motor nerve, ex- 
cept for the fibers it receives from the chorda tympani, destructive 



684 PHYSICAL DIAGNOSIS 

lesions in its center, or origin, or along its course through the 
aqueduct producing facial paralysis. In this form of paralysis 
the normal flexion folds disappear from the affected side of the 
face, the patient is unable to close the eye, which remains open 
and staring, is unable to whistle or smile, the angle of the mouth 
droops on the paralyzed side, while the opposite angle is drawn 
toward the healthy side. These changes constitute the typical 
Bell's palsy, which is due to a lesion of the nerve after its exit 
from the stylomastoid foramen, and which is often due to exposure 
to cold. 

If the lesion be situated in the aqueductus fallopii, in which 
situation the nerve is very susceptible to pressure from disease 
of adjacent structures, in addition to the signs of unilateral 
facial paralysis, the sense of taste is abolished over the dis- 
tribution of the chorda tympani. 

If the lesion involves the nucleus of origin of the nerve, or the 
root fibers or trunk, prior to its entry into the internal auditory 
meatus, there is usually, in addition to the other signs, hyper- 
acuteness of hearing due to paralysis of the stapedius muscle, 
which receives a branch of supply from the facial nerve as it 
traverses the aqueduct. 

In the case of a supranuclear lesion, a lesion involving the 
corona radiata and affecting only the supranuclear fibers, the 
main evidences of paralysis will be seen over the lower portion of 
the face, the muscles of the upper portion being affected to a 
minor degree, owing to the fact that the muscles of this upper 
region always act in unison and derive a nerve supply from both 
cerebral hemispheres. 

THE AUDITORY NERVE 

The auditory nerve is composed of two distinctly differentiated 
sets of fibers: (1) cochlear fibers, which subserve the function of 
audition; and (2) vestibular fibers, which supply the semicircular 
canals and preside over equilibrium. 

Deafness. — Impairment of the function of audition may be the 
result of local disease of the middle ear or of disease of the 
cochlear division of the auditory nerve. The acuity of hearing 
in the two ears may be determined by means of a watch, each 
ear being alternately occluded while the opposite ear is under 
examination, or by means of the vibrations of a tuning fork. In 
differentiating between middle ear deafness and nerve deafness 



THE CRANIAL NERVES 685 

the tuning fork should be applied to the midline of the forehead. 
Under these conditions, if the cause of the deafness lies in middle 
ear disease, the vibrations are most clearly audible in the diseased 
ear; whereas if it is a case of nerve deafness due to a lesion of 
the eighth nerve, the vibrations are audible only on the side of the 
sound ear. 

Tinnitus. — Tinnitus aurium, or ringing in the ears, occurs 
with intracranial tumors and aneurysm, temporary obstruction of 
the eustachian tube during acute colds, and during disease of the 
labyrinth. 

Vertigo. — Vertigo, or dizziness, when not of gastrointestinal 
origin, signifies a cerebral or intracranial lesion such as tumor or 
aneurysm acting upon the cerebellar centers of coordination or 
the afferent paths of the vestibular division of the auditory nerve. 
Tumors of the cerebellum are characterized by extreme vertigo 
and incoordination. Vertigo may be due to Meniere's disease or 
aural vertigo. 

THE BARANY TESTS 

The value of the Bar any tests in the localization of intracranial 
lesions depends upon certain fairly constant variations in the re- 
actions which are elicited upon stimulation of the static laby- 
rinth in the normal subject and in the presence of certain de- 
partures from the normal state. There are three principal 
reactions from^ this stimulation; namely, (1) the eye-pull, or 
nystagmus; (2) vertigo, or dizziness; and (3) past pointing or 
falling. Falling really constitutes past pointing with the trunk. 

The static labyrinth, comprising the semicircular canals to- 
gether with the utricle and saccule, is stimulated primarily and 
essentially by movements or currents which are induced in the 
endolymph content. This movement of the endolymph may be 
induced by rotating the patient in a smoothly revolving chair; 
by douching the external auditory canal with warm or with cold 
water; or by the electrode applied to the wall of the external 
auditory canal. 

The methods employed in eliciting the vestibular reactions have 
been variously modified to meet clinical demands. A brief and 
practical routine examination is outlined below. 

I. Direct Objective Examination. — (1) Spontaneous Nystag- 
mus. — In the routine examination it is convenient to test the spon- 
taneous eye-pull or nystagmus first, if any be present. For this 
purpose the patient is seated in the examining chair, which in this 



686 PHYSICAL DIAGNOSIS 

test remains stationary; and instead of directing the subject of 
the examination to follow with the globes the finger of the exam- 
iner as it is moved vertically and to the extreme right and left 
as has been the custom heretofore, it is simpler technic to have 
him fix the vision upon an object directly before him and at some 
distance, the examiner meanwhile rotating the chair slightly to 
the right and to the left. In the detection of minor grades of 
horizontal nystagmus it is well to seat the patient facing a win- 
dow in order to secure a good light reflex upon the cornea, since 
by carefully observing this reflex as the chair is slowly rotated 
to the right and to the left the examiner may readily detect 
slight oscillations of the globes. 

In interpreting the results of this test it is to be borne in mind 
that a few jerks of the globes upon rotation to the extreme right 
or left do not constitute a pathologic finding. Such a nystagmus 
is physiologic ; but it is important to remember that this physio- 
logic nystagmus is bilateral; and that a patient presenting a 
physiologic nystagmus toward the right should also present 
the same eye-pull in the opposite direction. 

Spontaneous nystagmus in the vertical direction is tested for 
by directing the subject, seated in the chair and facing a window, 
to alternately rotate the globes upward toward the ceiling and 
downward toward the floor. In neither event is a spontaneous 
nystagmus to be considered a normal finding, vertical nystagmus 
being held by Jones to be significant of a brainstem lesion. 

(2) Spontaneous Past-Pointing. — The ability of the subject to 
execute accurately certain pointing tests is next investigated. 
With the eyes lightly bandaged the subject is required to touch 
the index finger of the examiner; to raise his arm above the head 
and to come back to the finger of the examiner, which remains 
stationary. This pointing test may be executed as well by direct- 
ing the subject to lower the arm to the side and to come back to 
the examiner's finger; but of the two methods the former is pref- 
erable. 

The normal subject experiences no difficulty in executing this 
simple test. A patient with a cerebellar lesion, however, has 
a marked tendency to err toward the side of his lesion ; or in other 
words, will point toward the side of his lesion. 

(3) The Station; Spontaneous Falling. — The station is tested 
by directing the subject to stand upright with the feet closely 
approximated at heels and toes and with the eyes bandaged. 
Whereas a normal subject under these circumstances will exhibit 



THE CRANIAL NERVES 687 

at most a moderate swaying, a patient with cerebellar disease will 
exhibit a tendency to fall, and the falling is in the direction of 
his lesion. Thus, in the case of a lesion involving a lateral lobe 
of the cerebellum the tendency is to fall toward the side of the 
diseased lobe. Similarly in the case of a lesion of the anterior 
portion of the vermis the patient tends to fall forward; while 
with a lesion of the posterior region of the vermis the tendency 
is to fall backward. 

For the detection of a latent tendency toward falling the goniom- 
eter is employed. This apparatus consists of a movable plat- 
form, one side of which can be depressed while the opposite side 
rises along a graduated scale. The subject of the examination 
stands upon the platform, which is gradually tilted and the point 
on the scale is noted at which he is unable to compensate for the 
tilting and to maintain his balance. The test is applied first with 
the eyes open and afterward with the eyes bandaged. 

The station is further tested by the pelvic girdle test, or the 
''attempt to overthrow." In practicing this maneuver the patient 
should assume the upright attitude, with the heels and toes closely 
approximated and with the eyes bandaged, while the examiner by 
grasping the shoulders of the patient, attempts to overthrow him 
in the several directions, the patient endeavoring in the mean- 
while to compensate by a movement at the hips. Whereas a 
normal subject possesses a considerable degree of compensation 
at the hips, this compensation is entirely lacking in a patient with 
a cerebellar lesion, Avho is readily overthrown by this maneuver. 

II. The Turning Tests. — The turning or rotation tests are em- 
ployed for the purpose of eliciting induced reactions from the 
static labyrinth in contradistinction from the direct examination, 
which reveals only spontaneous reactions. In the application of 
the turning tests the subject is seated in a smoothly revolving 
chair, which may be rotated toward the right and toward the left 
at a uniform speed. 

The manner of construction of the chair has a very important 
influence upon the nature and constancy of the reactions which 
are elicited upon rotation of the subject of the examination. The 
chair should be provided with an adjustable headrest which will 
maintain the head in any desired position; and the base of the 
chair must be sufficiently heavy to prevent any deviation of the 
patient during the rotation. The headrest should occupy such 
a position with relation to the body of the chair that during 
rotation the head is in the center of the axis of rotation during 



688 PHYSICAL DIAGNOSIS 

the tests ; and the chair should be equip*ped with a second de- 
tachable headrest for maintaining the head in a fixed position 
when the patient bends forward. Moreover, a satisfactory chair 
should be equipped with a foot pedal which will bring the chair 
to an abrupt stop after the proper number of rotations. All of 
these essentials were not met by the chair which was originally 
devised by Barany, or by some of the chairs which are at present 
on the market. 

In the elicitation of nystagmus from stimulation of the hori- 
zontal semicircular canals, the patient is seated in the chair with 
the head inclined thirty degrees forward and held firmly in 
this position by the headrest. This position of the head places 
the horizontal canals parallel with the floor and the vertical 
canals perpendicular to this plane. Hence, rotation with the head 
in this attitude permits stimulation of the horizontal canals alone. 
In this position the patient is rotated toward the right at the 
rate of ten times in twenty seconds and the resulting eye-pull or 
nystagmus is noted. Accuracy in timing this maneuver calls for 
the use of a stopwatch; and in order that the rotation may be 
performed at a uniform speed, exactly two seconds should be 
allowed per turn. The patient is rotated similarly toward the 
left and the result is noted, the amplitude and duration of the 
nystagmus being in each case recorded. 

The nystagmus following rotation is composed of two compo- 
nents. The first component is the slower of the two, and occurs 
in the direction of the rotation, which corresponds to the direc- 
tion of the endolymph current which is induced in the semi- 
circular canals. This movement of the globes is the true or vestib- 
ular component, and is due directly to the vestibular stimulation. 
The second or rapid component occurs in the opposite direction, 
and is a compensatory reactionwhich is initiated by the cerebrum 
in its endeavor to restore the globes to their proper positions in 
relation to the orbits. In recording the nystagmus the accepted 
rule is to record the duration of the rapid component instead of 
that of the slow component, which in reality represents the de- 
gree of vestibular stimulation. The average duration of the 
nystagmus from stimulation of the horizontal semicircular canals, 
following rotation of the normal subject, is twenty-six seconds. 

The nervous impulse which results in nystagmus after rotation 
toward the right, with the head inclined forward at an angle of 
thirty degrees, travels over the vestibular division of the eighth 



THE CRANIAL NERVES 689 

cranial nerve to the brainstem and passes to the nucleus of 
Deiters. From this nucleus the impulse passes to the posterior 
longitudinal bundle, and through the medium of this fasciculus 
to the nucleus of origin of the sixth cranial nerve upon the right 
side and to the nucleus of origin of the third cranial nerve upon 
the left side. As the result of this afferent stimulation, the sixth 
nerve nucleus of the right side sends an impulse to the external 
rectus muscle of the right globe; while the third nerve nucleus 
sends an impulse to the internal rectus muscle of the left globe, 
with the resulting nystagmus or eye-pull toward the right side 
of the body. After rotation of the subject toward the left the 
afferent nervous pathway is the same, except that from the poste- 
rior longitudinal bundle the impulse passes to the sixth nerve 
nucleus of the left side and to the third nerve nucleus of the right 
side, with the production of a consequent nystagmus or eye-pull 
toward the left side of the body. 

Total absence of nystagmus or eye-pull following rotation is 
significant of a lesion of the posterior longitudinal bundle, which 
interrupts the transmission of the nystagmus-producing impulses. 

In the induction of vertigo from stimulation of the horizontal 
semicircular canals, the patient, seated in the chair with the 
head inclined forward at an angle of thirty degrees, is rotated 
toward the right at the rate of ten revolutions in ten seconds; and 
at the completion of the tenth turn the chair is brought to an 
abrupt stop. . 

As the patient is smoothly rotated toward the right at this 
uniform rate of speed, the endolymph content of the horizontal 
canals in the first instance lags behind; and the patient feels 
that he is being turned toward the right, as the cerebrum through 
previous experience has learned to interpret this common sensa- 
tion as motion of the body toward the right. After a few rota- 
tions, however, the endolymph content gains momentum and 
catches up with the movement of the canal in its progress, and the 
patient during a brief interval is unable to determine whether or 
not he is turning. Upon suddenly arresting the motion of the 
chair upon the completion of the tenth turn the onward progress 
of the canal is interrupted ; but the endolymph continues to surge 
onward, causing the patient to experience the subjective sensation 
which the cerebrum has learned through previous experience to 
interpret as movement of the body toward the left. 

The duration of the vertigo which is induced by rotation may 
be estimated either by having the subject of the examination to 



690 PHYSICAL DIAGNOSIS 

indicate the direction in which he feels tha^t he is turning, or by 
the maneuver of past-pointing. In the first instance, as the subject 
is rotated toward the right, during the first few turns he will in- 
variably state that he feels that he is turning toward the right. 
Soon, however, he reaches the point at which he is unable to state 
definitely in which direction he is turning. When, upon the com- 
pletion of the tenth turn, the chair is brought to an abrupt stop, 
the patient states that he is turning toward the left- and he is 
directed to continue to indicate the direction until the false sense 
of motion, or the vertigo, disappears. 

The eyes of the subject are lightly bandaged throughout the 
rotation tests. 

In testing the duration of the vertigo by past-pointing, as 
soon as the chair is brought to a stop, the examiner seizes the 
right hand of the patient, who is directed to raise the arm above 
the shoulder and to bring it back to the finger of the examiner, 
the degree of deviation of the arm or of past-pointing being 
recorded in inches. The same maneuver is performed with the 
left arm and then again with the right arm, the two arms being 
raised alternately until the subject of the examination succeeds 
in touching accurately the finger of the examiner. 

As the subject who has been rotated toward the right feels that 
he is turning toward the left, in the attempt to meet the finger 
of the examiner he will make allowance for this fictitious movement, 
and in his past-pointing will err toward the right. The extent 
of the error or deviation is recorded in inches toward the right. 
In the elicitation of past-pointing, the vertical excursion of the 
arm should not be unduly rapid, as sufficient time must be allowed 
for the induced vertigo to manifest itself in the downward move- 
ment of the arm. 

The afferent impulse which results in vertigo upon stimulation 
of the horizontal canals passes by way of the vestibular division 
of the auditory nerve to the nucleus of Deiters. This constitutes 
the common pathway for all aff^erent impulses emanating from 
the static labyrinth. At the nucleus of Deiters, however, the 
pathways separate, the fibers conducting vertigo impulses pur- 
suing a course through the brain which is separate and distinct 
from those which convey nystagmus impulses. From the nucleus 
of Deiters, instead of passing to the posterior longitudinal bun- 
dle as do the tracts for nystagmus, the vertigo-carrying fibers 
pass through the inferior cerebellar peduncle to the cerebellum, 
where they terminate in the cerebellar nuclei (globosus, emboli- 



THE CRANIAL NERVES 691 

f oralis, and fastigii). From these nuclei the tract passes through 
the superior cerebellar peduncle into the crus cerebri upon either 
side, where the tracts from the two sides undergo a decussation, 
the major portion of the fibers from each tract passing upward 
through the internal capsule and corona radiata to the vertigo 
center in the posterior portion of the second temporal convolu- 
tion, upon the opposite side of the brain from the static labyrinth 
which was stimulated by the rotation. However, a minor portion 
of the fibers terminate in the vertigo center of the corresponding 
side of the brain, the fibers not decussating in the crus cerebri. 

Basing conclusions upon these anatomical considerations, a 
total absence of vertigo upon stimulation of the horizontal canals, 
in the absence of middle ear disease, would signify a lesion of 
the crura cerebri, involving both vertigo tracts at the point of 
decussion, or lesions involving simultaneously both vertigo cen- 
ters in the cerebral cortex. 

The motor impulses which are directly concerned with past- 
pointing pass over what has been designated as the ''power 
tract." This nervous impulse passes by an association bundle 
from the vertigo center in the second temporal convolution to 
the motor center for the arm in the precentral gyrus, whence a 
motor impulse travels downward through the corona radiata, in- 
ternal capsule, crura cerebri and pons, and enters the medulla 
oblongata, where the fibers cross to the opposite side in the decussa- 
tion of the pyramids. The tract enters the lateral column of the 
spinal cord, to terminate in the cells of the anterior horns of the 
gray matter. Through the medium of these cells the impulse is 
relayed by way of the brachial plexus to the muscles of the 
shoulder girdle and arm, causing the arm to be raised and low- 
ered. 

The control of the brachial movements in past-pointing is 
exercised through a tract which may for want of a better name 
be designated the "accuracy tract." The course which is pur- 
sued by this tract has not been demonstrated histologically, but 
its course has been inferred from clinical evidence to be as is 
given below. 

Passing downward from the cerebral cortex through the in- 
ternal capsule, the tract enters the pons and there decussates and 
passes to the cerebellar nuclei (globosus, emboliformis, and 
fastigii) of the opposite side, probably by way of the superior 
cerebellar peduncle. From these nuclei the fibers pass to the 



692 PHYSICAL DIAGNOSIS 

nucleus dentatus, and thence to the pointing centers in the cere- 
bellar cortex. 

Barany described four pointing centers in the cerebellar cor- 
tex for upward, downward, inward, and outward movement, re- 
spectively. When all of these centers are functioning properly, 
the accuracy tract produces perfect coordination in the brachial 
movements. A lesion of any of these centers results in imbalance 
of the delicate coordinating mechanism, with consequent devia- 
tion, spontaneous or latent. 

From the pointing centers in the cerebellar cortex, the fibers 
of the accuracy tract are assumed to pass back, probably again 
traversing the nucleus dentatus, and through the inferior cere- 
bellar peduncle to the medulla and the lateral columns of the 
spinal cord. 

In the elicitation of nystagmus and vertigo from stimulation 
of the vertical semicircular canals by rotation, the subject as- 
sumes a different attitude in the chair. In this instance the 
head is inclined at an angle of 120° forward, by directing the pa- 
tient to bend forward and to rest the forehead upon the headrest 
which is supported by a metal bar passing between the arms of 
the chair. In this position the vertical canals are brought into 
a plane parallel with the floor, which permits movements of the 
endolymph content of these canals to be induced by rotation. 

With the head in this position the subject is rotated alter- 
nately toward the right and toward the left at the rate of five 
rotations in ten seconds. The nystagmus which is induced in this 
manner is not horizontal as in the case of similar stimulation of 
the horizontal canals, but is rotary. Moreover, as the patient 
straightens the body upon the completion of the last turn, he 
exhibits a tendency to fall, which constitutes a past-pointing with 
the trunk. After rotation with the horizontal semicircular canals 
parallel with the floor the patient exhibits no tendency toward 
falling, as the vertigo in this instance is on a plane with the floor. 

The impulse which is induced upon stimulation of the vertical 
canals passes to the brainstem over the vestibular division of the 
eighth cranial nerve. This tract, after entering the brainstem, 
does not make connections with the nucleus of Deiters, but as- 
cends in the pons, presumably close to the median line, to a 
point as yet undetermined but probably as high as the junction 
of the middle and upper thirds of the pons. At this hypothetical 
level the fibers separate, the fibers conveying nystagmus-produc- 



THE CRANIAL NERVES 693 

ing impulses and those transmitting vertigo-producing impulses 
pursuing different courses through the brain. 

The fibers for nystagmus pass to the posterior longitudinal 
bundle and through this medium make connections with the 
nuclei of origin of the third and fourth cranial nerves. 

The fibers conducting the vertigo-producing impulses from 
the vertical canals, after ascending in the pons to the hypo- 
thetical nucleus, leave this cell station and the tract passes to 
the cerebellum through the middle cerebellar peduncle. Within 
the cerebellum the tract terminates in the cerebellar nuclei, 
w^hence the course is the same as that pursued by the fibers from 
the horizontal canals previously described. 

The terminal station in both instances is the vertigo center 
in the cerebral cortex. 

In the interpretation of the results of the rotation tests, it 
simplifies matters to bear in mind the general principles that the 
eye-pull or nystagmus always occurs in the direction of the endo- 
lymph movement ; that vertigo is always manifested in the direc- 
tion opposite to the endolymph movement ; and that past-pointing, 
the clinical manifestation of induced vertigo, occurs in the direc- 
tion opposite to the vertigo. 

III. The Caloric Tests. — The principal value of the caloric 
tests resides in the fact that by this method either labyrinth may 
be tested separately, whereas rotation produces simultaneous 
stimulation of both labyrinths. 

In practicing the caloric tests, cold or warmed water may be 
employed. By cold water is understood water which is constantly 
maintained at a temperature of 68° F. throughout the test. By 
warmed water is understood water which is maintained at a 
temperature of 112° F. during the test. In the routine examina- 
tion cold water is ordinarily used, and it is seldom found neces- 
sary to employ warm irrigations. 

When the external auditory canal is irrigated with cold or 
warm water of constant temperature, convection currents are in- 
duced in the endolymph content of the semicircular canals, which 
rises and falls with these changes of temperature. Consequently 
only those canals which occupy a vertical position at the time of 
the irrigation are stimulated by the caloric test. 

During the irrigation of the external auditory canal the head 
should be inclined forward at an angle of thirty degrees in order 
to bring the horizontal canals on a horizontal plane with the 
floor, and the vertical canals perpendicular to the floor. 



694 



PHYSICAL DIAGNOSIS 



TABLE SHOWING CLINICAL FACTS UPON WHICH EQUILIBRIUM TESTS ARE BASED* 







In Labyrinthine 
Disease 


In Cerebellar 
Disease 


Normal Individual 


<L) 

rj 


Falls 


Toward the affected 
ear. 

Direction can be 
changed by rotat- 
ing head on 
shoulders. 


Fither way;" most 
often toward the 
side of lesion. 


Does not fall. 


O 


Nystagmus 


Jerky toward side 
opposite to that 
of the lesion. 


Steady; hard to 
determine direc- 
t i n; most 


No nystagmus. 








marked away 
from the side of 
the lesion. 




w 


Points 


Towards the side 
of the lesion with 
either hand. 


Toward the side of 
lesion with hand 
on that side; 


Points normally. 


Q 






may point nor- 
mally with other 
hand. 






c 
o 

(U 

o 


Falls 


Toward the affected 
internal ear no 
matter how head 
is placed. 


Any way ; most 
likely toward side 
of the lesion. 


Toward the ear 
tested. 


bo 


Nystagmus 


Jerky away from 
the side of the 
lesion. 


Steady; most 
marked away 
from side of the 
lesion or may be 
jerky away from 
the side of the 


Away from the side 
of the ear tested, 
jerky. 


u. 2 


O 

o 

(U 






lesion. 




(U 

II 


Points 


Toward the side of 
the lesion with 
either hand. 


Points to side of 
lesion with hand 
on side of lesion; 
hand on well side 
shows no change 
or points to side 
of lesion. 


Toward the side of 
the ear tested 
with either hand. 




Falls 


Fither way; most 
likely to side of 
the lesion. 


Away from the side 
of the lesion. 


Toward the ear 
tested. 


•S^ 










bfl ni 


&.2 
O 


Nystagmus 


Jerky, both direc- 
tions; most 
marked away 
from side of le- 
sion. 


Jerky toward the 
side of the le- 
sion. 


Away from the side 
of the ear tested, 
jerky. 


< 


Points 


Fither way with 
either hand, most 
likely towards the 
side of the le- 
sion with either 
hand. 


Toward the side of 
lesion with hand 
on that side; 
away from side 
of lesion with 
other hand. 


Toward the side of 
the ear tested 
with either hand. 



Courtesy of Dr. C. F. Shinkle. 



THE CRANIAL NERVES 



695 



TABLE SHOWING CLINICAL FACTS UPON WHICH EQUILIBRIUM TESTS ARE BASED^ 

(Continued.) 









In Labyrinthine 
Disease 


In Cerebellar 
Disease 


Normal Individual 


.S 


C 

.2 

o 

<U 

■l-i 

o 


Falls 


Toward the af- 
fected internal 
ear most often. 


Any way; most of- 
ten away from 
the side of le- 
sion. 


Away from the ear 
tested. 


o 


Nystagmus 


Jerky toward side 
opposite to that 
of the lesion. 


Steady; perhaps 
jerky towards the 
side of lesion. 


Toward the side of 
the ear tested, 
jerky. 


a 1-1 


Points 


Confused; most of- 
ten toward the 
side of lesion 
with either hand. 


Toward the side of 
lesion with hand 
on side of the le- 
sion; other hand 
does not vary or 
points away from 
lesion. 


Away from the side 
of the ear tested 
with either hand. 


c o 


o 

'L 

<U 

O 


Falls 


Toward the af- 
f e c t e d internal 
ear, no matter 
how head is 
placed. 


Toward the side of 
lesion. 


Away from side of 
ear tested. 


OJ 


Nystagmus 


Jerky toward side 
opposite to that 
of the lesion. 


Jerky toward the 
side opposite to 
that of the le- 
sion. 


Toward the side of 
ear tested, jerky. 


Points 


Toward the side of 
the lesion with 
either hand. 


Toward the side of 
lesion with either 
hand. 


Away from the side 
of the ear tested 
with either hand. 






Falls 


Toward the side of 
the lesion. 


Toward the side of 
lesion. 


In same direction 
as that of rota- 
tion. 




Nystagmus 


Jerky away from 
side of lesion. 


Jerky away from 
the side of the 
lesion. 


Jerky in direction 
opposite to that 
of rotation. 


'1 


Points 


Toward side of le- 
sion with either 
hand.. 


Toward the side of 
lesion with either 
hand. 


In same direction 
as that of rota- 
tion. 


<u 


rs 

4 


Falls 


Toward the side of 
the lesion. 


Fither way; most 
likely away from 
side of lesion. 


In same direction 
as that of rota- 
tion. 


Is 

1 


Nystagmus 


Jerky away from 
the side of the 
lesion. 


Steady or perhaps 
jerky; if the lat- 
ter, direction is 
toward the side 
of lesion. 


Jerky in direction 
opposite_ to that 
of rotation. 


Points 


Towards the side 
of the lesion with 
either hand. 


Toward the lesion 
with hand _ on 
side of lesion; 
away from lesion 
with other hand, 
if any change at 
all. 


In same direction 
as that of rota- 
tion. 



^Courtesy of Dr. C. F. Shinkle. 



696 PHYSICAL DIAGNOSIS 

Nystagmus under these circumstances ifsually is manifested 
after forty seconds of irrigation, although a delay of twenty 
seconds over this figure is not to be considered pathologic. Irri- 
gation of the right external auditory canal produces rotary 
nystagmus toward the right, and vice versa. The amplitude and 
character of the nystagmus is recorded in each instance. 

The vertigo which is induced by irrigation of the right canal 
causes the subject to feel that he is falling toward the left; hence, 
he errs toward the right in his past-pointing. 

If, in addition, it is deemed advisable to test the reaction of 
the horizontal canals to caloric stimulation, the head is turned 
backward at an angle of sixty degrees, which brings the horizon- 
tal canals into a vertical direction, and the convection currents 
which are induced in the endolymph pass through the horizontal 
canals, producing a horizontal nystagmus toward the side of 
the irrigation. 

The usual results following labyrinthine stimulation in the 
normal subject, in the presence of labyrinthine disease, and in 
the presence of cerebellar lesions, are tabulated in the accompany- 
ing table, which was complied by Dr. C. E. Shinkle. 

THE GLOSSOPHARYNGEAL NERVE 

The glossopharyngeal nerve supplies sensory fibers to the 
mucous membrane of the pharynx and to the posterior third of 
the tongue. It is also the motor nerve of the middle constrictor 
of the pharynx and the stylopharyngeus. 

Paralysis of the nerve is evinced by loss of taste sensation for 
the posterior third of the tongue and abolition of the pharyngeal 
reflex. Lesions of the nucleus of the nerve do not affect the sen- 
sation of taste owing to communications of the taste fibers with 
the trigeminal nerve. 

THE PNEUMOGASTRIC NERVE 

The pneumogastric, or vagus nerve, arises from a nucleus 
beneath the floor of the fourth ventricle along with the nucleus 
of origin of the glossopharyngeal nerve. The nerve has a very 
extensive distribution, supplying motor fibers to the palate, 
pharynx, and larynx. It also sends fibers to the esophagus, 
stomach, heart, lungs, and through the sympathetic system to 
the intestines and spleen. 

Paralysis of the pneumogastric nerve produces unilateral paral- 
ysis of the palate. 'This paralysis is demonstrated by observing 



THE CRANIAL NERVES 697 

the excursion of the palate while the patient pronounces a syl- 
lable, such as the word ''Ah," when only half of the palate 
rises in the normal manner. In a patient with palatal paralysis 
fluids which are ingested have a tendency to regurgitate through 
the nose. The speech is impaired, assuming a nasal quality, ow- 
ing to impairment of the innervation of the vocal cords. In uni- 
lateral recurrent laryngeal paralysis phonation is impaired but 
not abolished; but in bilateral recurrent laryngeal paralysis 
phonation becomes impossible. 

THE SPINAL ACCESSORY NERVE 

The spinal accessory nerve consists of two divisions: (1) the 
spinal, which arises from the anterior horns of the cervical cord 
as low as the fifth cervical nerve; and (2) the accessory, which 
arises from a nucleus situated near that for the pneumo gastric 
nerve. The fibers of the spinal division of the nerve are dis- 
tributed to the sternomastoid and trapezius muscles, while the 
fibers arising from the accessory nucleus are distributed to the 
pharyngeal and superior laryngeal nerves. 

In testing the spinal portion of the nerve the patient is di- 
rected to rotate the head and to shrug the shoulders. In paraly- 
sis of this division of the nerve paralysis of the sternomastoid on 
the corresponding side causes difficulty in turning the head 
toward the sound side. Paralysis of the trapezius muscle is re- 
vealed by inability to shrug the shoulder. 

THE HYPOGLOSSAL NERVE 

The hypoglossal nerve takes origin from a center in the loAver 
portion of the floor of the fourth ventricle. The nerve trunk 
emerges in a series of fascicles in the interval betAveen the an- 
terior pyramid and the olivary body. 

The hypoglossal nerve supplies motor fibers to the tongue and 
sends motor fibers to all the muscles attached to the hyoid bone 
with the exception of the digastric, middle constrictor of the 
pharynx, mylohyoid and stylohyoid. 

Unilateral hypoglossal paralysis is demonstrated by direct- 
ing the patient to protrude the tongue, when it will be ob- 
served to deviate toward the paralyzed side. There is or is not 
atrophy depending on whether the lesion causing the paralysis is 
supranuclear or infranuclear. 

In bilateral hypoglossal paralysis the patient is unable to pro- 
trude the tongue. 



APPENDIX 



CASE HISTORY 

Case Number Date. 

PERSONAL DATA 

Name Address _ 

Sex Age 



Occupation Nativity 

Civil state . Number of children. 

Pathologic labors Miscarriages 



FAMILY HISTORY 

Health of parents Age and cause of death 

Health and age of sisters . 

Health and age of brothers 

Age and cause of death of sisters 

Age and cause of death of brothers 

Special history of tuberculosis^ syphilis, epilepsy, insanity, gout, and diabetes 
in family 

PREVIOUS HISTORY 

User of tobacco, alcohol or narcotic drugs 

When and for what period_j Dates of treat- 
ment for same 

Venereal disease (gonorrhea and syphilis) 

Dates of treatment 

Diseases during childhood (Varicella, scarlatina, mumps, pertussis, diphtheria) 

Infectious diseases (Pneumonia, tuberculosis, diphtheria, otitis, cerebrospinal 

meningitis, typhoid fever) 

Dates Complications 

Former attack of present complaint 

Date Mode of onset 

Former injuries Residual deformities 

Recent loss of weight 

PRESENT ILLNESS 

Date and mode of onset Treatment 

Evolution of disease to date . 

Subjective symptoms 



APPENDIX 



699 



PHYSICAL EXAMINATION 



Height ft. 



Weight lbs. 



RESPIRATORY SYSTEM 

Inspection : 
Herpes labialis State of alae nasi 

Cervical veins Contour of chest 

Clavicles Supra- and infraclavicular fossae. 

Unilateral enlargement 

Unilateral retraction 

Local bulging Local retraction 



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Fig. 308. 



700 PHYSICAL DIAGNOSIS 

Type of respiratory expansion (Costal or abdominal) 

Respiration sterterous, stridulous or jerky 

Dyspnea Inspiratory Expiratory 

Mixed Cyanosis 

Cheyne-Stokes breathing Litten's Phenomenon 

Present Absent 

Expansion of thorax: General increase General 

decrease Unilateral increase 

Unilateral decrease Wavy breathing 

Palpation : 

Expansion of apices Expansion of bases 

Antero-posterior expansion 

Vocal fremitus: Normal Exaggerated 

Diminished Friction fremitus 

Ehonchal fremitus Tussile fremitus 

Succussion fremitus . Sense of resistance: Normal 

Increased Decreased 

Local tenderness Fluctuation 

Crepitation Local pulsations 

Percussion : 

Normal limits of resonance : Increased resonance: 

Upward Downward ^ Anteriorly over heart 

Dullness or impaired resonance Sites 

Flatness Sites and dimensions^ 

Hyperresonance Skodaic resonance 

Tympany Signs of cavity or excavation: Cracked-pot 

sound Wintrich's change of sound Interrupted 

Wintrich's change of sound Gerhardt's change of sound 

Friedreich's change of sound 

Amphoric resonance Grocco's sign 

Resistance Increased Decreased 

Auscultation : 

Breath sounds: Vesicular Increased Decreased 

Bronchial Site Increased Decreased 

Broncho-vesicular Site Amphoric Site 

Cavernous Site Puerile Sites 

Prolonged expiration Cog-wheel breathing 

Vocal resonance Increased Diminished 

Bronchophony Pectoriloquy Whispering pectoriloquy 

Aegophony Absent respiratory and voice sounds 

Sites Rales Sibilant 

Sonorous Sites Crepitant Subcrepitant 

Mucous Sites Pleural friction 

Metallic tinkle Succussion sound 

Mensuration Cyrtometry of chest 

Examination of sputum 



APPENDIX 



701 



CIRCULATORY SYSTEM 

In^spection: 

Precordial bulging Precordial retraction 

Abnormal pulsations Cardiac impulse : Site 

Extent Force Displacement Upward 

Upward and to left to left to left and downward. 

to right Absent or invisible 

Systolic retraction (Broadbent's sign) 

Overfullness of jugulars (Kussmaul's sign) Diastolic 

collapse of jugulars (Friedreich's sign) 

Tortuous cutaneous veins Systolic jugular pulsations 

Hepatic pulsation Capillary pulse 



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309. 



702 PHYSICAL DIAGNOSIS 

Palpation : ■ * 
Thrills Sites Time 

Pericardial friction Valve shock 

The pulse Condition of artery Rate Ehythm. 

Volume Tension Omission Intermission. 

Bilateral symmetry Dicrotism 

Percussion : 

Cardiac borders Increase to right To left 

To left and downwards General increase 

Vascular dullness Increased to right 



Auscultation : 

Heart sounds: General accentuation General diminution 

Accentuation first sound Accentuation second 

Reduplication first sound Reduplication second sound 

Endocardiac murmurs Site P.M.I 

Line of transmission Time Quality 

Intensity Pericardial friction 

Pericardial succussion Flint murmur 

Venous hum Aortic murmurs ; 

Examination of the blood: Hemoglobin Leukocytes: Numerical 

Differential Erythrocytes Numerical 

Parasites Polychromatophilia 

Blood pressure Systolic pressure Diastolic pressure 

Pulse pressure 

THE ABDOMEN 

Inspection : 

Distended veins Caput Medusae Diastasis 

Visible peristalsis Tumor Pigmentation 

Scars Umbilicus Hernia 



Palpation: 

Thickness of wall Tumor of wall Fluid wave. 

Fat wave Muscular rigidity 

Muscular spasm Tenderness Site 



SPECIAL ABDOMINAL ORGANS 

The Stomach: 

Position greater curvature Lesser curvature 

Gastrectasis Gastroptosis 

Visible peristalsis Pyloric tumor 

Hour-glass constriction Tenderness 

Succussion Transillumination 

Gastric contents: Free HCl Combined HCl 

Lactic Acid Blood 

The Intestines : 

Tenderness Tumor Impacted feces 

Gaseous distention Visible peristalsis 



APPENDIX 703 

Examination of feces Parasites Ova Blood 

Color Consistence Undigested food 

The Pancreas: 

Tenderness Tumor Cyst 

Fat indigestion Cammidge Reaction 

The Liver and Gall Bladder: 

Enlargement Diminution 

Ptosis Tenderness Systolic pulsation 

Consistence Fluctuation 

Nodules Reidel's lobe Gall-bladder tumor 

Gall-stone crepitus Peritoneal friction 

The Spleen: 

Enlargement Diminution 

Displacement Tumor Peritoneal friction 

The Kidney: 

Tenderness Ptosis 1st degree 

2nd degree 3rd degree Cystic Tumor 

Urinalysis 

THE HEAD AND NECK 

The Head: 

Microcephalic Megalocephalic Rickets 

Hydrocephalus Cretinism Fontanelles: Depressed 

Bulging Sutures Craneotabes 

Condition of hair: Color General loss Localized loss 

The face: Contour Pallor Cyanosis Jaundice 

Chloasma Spasm Scars Eruptions 

The eyes: Edema of lids Exophthalmos Enophthalmos 

Strabismus Hippus Nystagmus Argyll- 
Robertson pupil Ocular mobility 

The Lips: Pallor Cyanosis Epithelioma 

Chancre; Fissures Parted lips 

The teeth: Premature decay Delayed dentition 

Hutchinson teeth Sordes 

The Gums: Spongy Lead line Copper line 

Red line Epulis Gingivitis 

The Tonsils: Chronic hypertrophy Tonsillitis 

Diphtheria Vincent 's angina 

The Ear: Deformity or injury Tophi Discharge 

The Nech: 

Cervical glands Thyroid 

Tracheal tug Sternomastoids Branchial 

cysts Torticollis Retraction 

THE HANDS AND ARMS 

Nails : Pallor Cyanosis 

White spots Incurvation Capillary pulse 



704 PHYSICAL DIAGNOSIS 

Fingers: TopM Nodes Clubbed fingers 

Enlarged joints Gangrene Manual deformities__. 

Tremor Wrist-drop Onychia 

Forearm: Rickets Pellagra Erythema multiforme. 

Arm: Ruptured biceps Tumors Paralysis 



THE FOOT AND LOWER EXTREMITY 



Gangrene Foot-drop 

Edema Ulceration Joints. 

Babinski's reflex Knee-jerk 



THE NERVOUS SYSTEM 

Headache Vomiting 

Paralysis Choked disk Convulsions 

Disorders of sensation Disturbances of speech 

Disorders of organs of special sense 

Pain, tremor Station Gait Reflexes. 

Diagnosis 

Complications 

Prognosis . 

Treatment 

Besult 

Discharged 



INDEX 



Abadie's sign, 610 

Abdomen, anatomical landmarks of, 
486 
anatomy, clinical, 485 

toj)ograj)hical, 489 
auscultation, 517 
color, 496 
contour of, 485, 501 

in ascites, 503 

in enteroptosis, 506 

in gastroptosis, 506 

in meteorism, 503 

in obesity, 501 

in pregnancy, 501 

normal, 501 
cutaneous flexion folds, 489 
enlargement, asymmetric, 509 

symmetric, 501 
eruptions, 496 
examination of, 485 

in dorsal decubitus, 495 

in knee-chest posture, 495 

in standing posture, 495 
fat wave, 514 
fluctuation, 513 
fluid wave, 513 
friction, 517 . 
glands, enlarged, 517 
inspection, 495 
mensuration, 518 
movements, absence of, 501 

respiratory, 501 
muscular rigidity, 513 
palpation, 511 
percussion, 516 
quadrants, 492 
regions, 490 
retraction, 51u 
scaphoid, 510 
scars, 495 
skin, 495 

tortuous veins, 496 
Abdominal aorta, 482, 489 
anatomy, clinical, 489 

aneurysm, 482 
cavity, 485 
tumor, 515 

viscera, examination of, 520 
wall, 485, 511 
Abscess, cervical, 634 

metastatic, in endocarditis, 420 
of brain, 286 



Abscess — Cont 'd. 
of liver, 566 
of lung, 283 

bronchogenic, 283 
decubitus in, 286 
diagnosis, 288 

differential, from bronchiecta- 
sis, 289 
empyema, 289 
pulmonary gangrene, 289 
phthisis, 289 
distribution, 285 
pathology, clinical, 283 
perforating, 284 
physical signs, 286 
pneumogenic, 284 
sputum in, 287 
perinephritic, 594 
postpharyngeal, 627 
psoas, 655 

perforating, of Stokes, 284 
tuberculous, 284 
Absence of septa of heart, 479 
Absent respiration, 154 
vocal fremitus, 101 
resonance, 156 
Accentuation, of cardiac sounds, 368 
Accidental murmurs, 390 
Accoucheur's hand, 644 
Acromegaly, 605, 641, 651 
facies of, 605 
foot of, 651 
spade hand of, 641 
Acute bronchitis, 205 (see Bronchitis, 
acute) 
emphysema, 281 

endocarditis, 418 (see Endocardi- 
tis, acute) 
fibrinous pericarditis, 407 (see Per- 
icarditis, fibrinous, acute) 
pleurisy, 297 (see Pleurisy, fibrin- 
ous, acute) 
myocarditis, 467 (see Myocarditis, 

acute) 
tuberculopneumonic phthisis, 250 
pneumonic phthisis, 252 
diagnosis, 254 
pathology, clinical, 252 
physical signs, 252 
bronchopneumonic phthisis, 254 
diagnosis, 255 
pathology, clinical, 255 
physical signs, 255 



705 



706 



INDEX 



Addison's disease 609, 625 

skin of, 609 

tongue of, 625 
Adenitis, inguinal, 654 
Adenoid vegetations, 615 
Adenopathy, chancroidal, 499 

luetic, 499 
Adhesions, pericardial, 413 

pleural, 311 
Adhesive pleurisy, chronic, 311 
Adventitious sounds 159, 380 
Aegophony, 158 (see egophony) 
Air hunger, of Kussmaul, 80 
Alar scapulae, 63 

thorax, 63 
Albinism, pulmonary, 276 
Allorhythmic pulse, 354 
Alveoli, pulmonary, 38 
Amblyopia, 675 
Amphoric resonance, 141, 142 

respiration, 153 

vocal resonance, 158 
Amphorophony, 158 
Anasarca, 55 
Anatomy, clinical, of abdomen, 485 

of aorta, 332 

of bladder, 596 

of bronchi, 33, 34 

of heart, 317 

of intestine, large, 534 
small, 532 

of kidneys, 583 

of larynx, 31, 32, 33 

of liver and gall bladder, 549 

of lungs, 34 

of mediastinum, 29 

of pancreas, 544 

of pericardium, 321 

of pleura, 28, 39 

of pleural cavity, 29 

of pulmonary artery, 324 

of spleen, 570 

of stomach, 520 

of thorax, 25 

of trachea, 33 

of viscera, abdominal, 486 
thoracic, 31 
Aneurysm, of aorta, abdominal, 330, 
482 

thoracic, 323, 480 
diagnosis, 484 
pathology, clinical, 480 
physical signs, 483 
rupture of^ 313, 323 

of axillary artery, 358 .' , '' 

of brachial artery, 358 

of heart, 468 

of innominate artery, 330, 358 

of subclavian artery, 330, 358 



Angina, Ludwig's, 635 

Vincent's, 628 
Angle, cardiohepatic of Ebstein, 121, 
130, 360 
dullness of, 130 
costal, 57, 61, 64 
acute, 64 

in chronic ulcerative phthisis, 64 
hypertrophic emphysema, 61 
rickets, 66 
obtuse, 61 
costovertebral, 588 
of Louis, 44 

as landmark of thorax, 44 
splenohepatic, 579 
splenopulmonary, 578 
splenorenal, 578 
Angulus Ludovici, 44, 62 

prominence of, 62 
Ankle clonus, 671 
Anosmia, 674 
Anthracosis, 269 
diagnosis, 272 

pathology, clinical, 269, 270 
physical signs, 271 
Anvil test, 144 
Aorta, 322 

aneurysm of, 323 
arch of, 323 
ascending, 323 
auscultation of, 394 
congenital defects, 324 
clinical anatomy, 322 
descending, 323 
pulsation, 329 
surface marking, 326 
Aortic area, 367 
incompetence, 425 
insufficiency, 425 
murmurs, 384 
diastolic, 386 
systolic, 385 
regurgitation, 425 
aortic sound in, 433 
capillary pulse in, 431 
Corrigan pulse in, 432 
diagnosis, 434 
double murmur in, 433 
Duroziez 's sign in, 434 
pathology, clinical, 425 
physical signs, 430 
relative, 426 

water-hammer pulse in, 432 
sound, accentuation of, 369 

diminutipn of, 370 
stenosis, 434 

button-hole - orifice in, 434 
diagnosis, 441 
pathology, clinical, 434 



INDEX 



707 



Aortic stenosis — Cont 'd. 
physical signs, 437 
pulse in, 439 
relative, 435 
thrill in, 438 
valve, 320 

anatomic site, 367 
auscultatory site, 367 
Ape-hand, 644 

Apex-beat, 334 (see Impulse, car- 
diac) 
absence of, 334 
displacement of, 336 
extent of, 339 
force of, 340 
site of, 334 
Apical pneumonia, 234 
Appendicitis, acute, 513, 539 
Appendix, vermiform, clinical anat- 
omy, 535 
palpation of, 538 
Arc, reflex, 666 
Arcus senilis, 613 
Arch, aortic, 323 

costal, 486 
Area, aortic, 367 

auscultatory of valves, 367 
mastoid, 187 
mitral, 367 

of dullness, cardiac, 359 
absolute, 359 
pulmonary, 368 
relative, 359 
tricuspid, 367 
variations in, 361 
hepatic, 563 
Argyll-Eobertson pupil, 679 
Argyria, 609 
Arm, atrophy, 649 
contracture, 648 
edema of, 647 
examination of, 647 
movements, 648 
nodes, 647 
paralysis, 647 
rigidity, 648 
spasm, 648 
tumor, 647 
Arrhythmia, 352 
cardiac, 372 

clinical types, 374 
extrasystolic, 378 
heart-block, 378 
intermittent, 375 
respiratory, 375 
simple, 374 
Arterial murmurs, 394 
diastolic, 394 
in aorta, 394 
in carotids, 394 
in femorals, 394 



Arterial murmurs — Cont 'd. 

in subclavians, 394 

systolic, 394 

pressure, estimation of, 396 

pulse, 346 

analysis of 350 
counting, 346 
• sphygmogram, 349 
variations in, 350 
technic of taking, 346 

wall, 350 
Artery, axillary, aneurysm of, 358 

brachial, aneurysm of, 358 

carotid, murmur of, 394 

changes in, 350 

coronary, 317 

epigastric, deep, 489 

femoral, auscultation of, 395 
double murmur in, 395 

iliac, common, 489 
external, 489 

pulmonary, 324 

surface marking, 326 

size of, 350 

subclavian, 394 
murmur in, 394 
Arthritis, 186 

atrophic, 186 

deformans, 640 

gonorrheal, 108, 186 

hypertrophic, 186 

infectious, 186 
Ascites, 503 

abdominal contour in, 503 
Aspiration, of f)leura, 175 

pneumonia, 240 
Astereognosis, 666 

Asthma, bronchial, 219 (see Bron- 
chial Asthma) 

cardiac, 219 

potter's, 271 

renal, 219 

spasmodic, 219 
Ataxia, 660 

locomotor, 650 
Ataxic gait, 660 
Atelectasis, 272 

acquired, 272 

compression, 272 

congenital, 272 

diagnosis, 274 

obturation, 224 

pathology, clinical, 272 

physical signs, 273 
Athetosis, 645 
Atrium, of auricle, 318 
Atrophic emphysema, 278 (see . Em- 
physema, atrophic) 
Atrophy, of arm, 649 

of heart, 337 

of nails, 638 



708 



INDEX 



Atrophy — Cont 'd. 

progressive muscular, 644, 651 
Attributes of percussion sound, 118 
Auenbrugger 's sign, 411 
Auricles, of heart, 318 
Auricular fibrillation, 379 
Auriculoventricular bundle, 321 

valve, 320 
Auscultation, 145, 366 
immediate, 145 
mediate, 146 
object of, 145 
of abdomen, 517 
of carotids, 394 
of gall bladder, 568 
of intestine, large, 543 

small, 535 
of jugulars, 395 
of kidneys, 596 
of liver, 568 

of lungs and bronchi, 145 
of precordia, 366 
of spleen, 582 
of stomach, 532 
of subclavians, 394 
technic, 145 
Auscultatory valve areas, 367 
percussion, 116 
of stomach, 529 
Axillary line, anterior, 46 
posterior, 46 
region, 49 

B 

Babinski's sign, 669 
Baccelli's sign, 157 

in serofibrinous pleurisy, 157 
Back, percussion of, 115 
Bamberger's sign, 412 
Banti's disease, 566 
Barany tests, 685 
Barrel chest, 60 

Beat, apex, 334 (see Impulse, car- 
diac) 
Bell tympany, 144 
Belt sign, Glenard's, 526 
Biceps, ruptured, 647 
Bicuspid valve, 320 
Biermer's phenomenon, 139 
Binaural stethoscope, 145 
Biot's respiration, 78 
Bladder, clinical anatomy, 596 

examination of, 597 
Blepharitis marginalis, 612 
Blepharospasm, 610 
Blood pressure, arterial, 396 

definition, 396 

diastolic, 397 

estimation of, 397 

auscultatory method, 401 
palpatory method, 399 



Blood pressure — Cont'd, 
normal variations, 402 
pathologic variations, 402 
phases, 401 
systolic, 397 
diminished, 403 
increased, 402 
venous, 405 

Oliver's method of estimation of, 
406 
Eones, cranial, 599, 601 
bosses, 599, 601 
craniotabes, 599, 601 
long, carcinoma of, 185 
cyst, 185 
exostosis, 185 
fracture, 176 
periostitis, 185 
osteoma, 185 
osteomyelitis, 185 
Borborygmus, 535 
Bowles stethoscope, 145 
Bowlegs, rachitic, 655 
Boxhead, rachitic, 599 
Bradycardia, 377 
Bradycardia, 377 
pathological, 377 
physiological, 377 
Stokes-Adams, 378 
Branchial cleft, 635 
cyst, 635 
fistula, 635 
Breast, funnel, 68 
hypertrophy, 55 
keel, 68 
pigeon, 68 
Breath, diabetic, 620 
foul, 620 
uremic, 620 
Breathing, 148 (see Eespiration) 
Bronchi, clinical anatomy, 33 
diseases of, 205 
stenosis, 224 
surface markings, 42 
Bronchial asthma, 219 

Charcot-Leyden crystals in, 219 
Ctirschmann 's sj)irals in, 219 
diagnosis, 223 

differential, 223 
eosinophiles in, 219 
pathology, clinical, 219 
physical signs, 221 
rales in, 222 
sputum in, 219 
Bronchiectasis, 214 
cylindric, 215 
diagnosis, 218 

differential, 218 
fusiform, 215 
pathology, clinical, 214 
physical signs, 217 



INDEX 



709 



Bronchiectasis — Cont 'd. 
saccular, 215 
universal, 215 
sputum in, 216 
Broncliiectatic cavities, 215 
pectoriloquy in, 218 
tympany in, 217 
Bronchiole, clinical anatomy, 37 

terminal, 37 
Bronchitis, acute, 205 
diagnosis, 207 

differential from bronchopneu- 
monia, 206 
lobar pneumonia, 206 
pertussis, 207 
pathology, clinical, 205 
physical signs, 205 
chronic, 207 
diagnosis, 211 

differential from bronchial 
asthma, 223 
phthisis. 212 
fetid, 209 
eosinophilic, 210 
fibrinous, 212 
mechanical, 207 
pathology, clinical, 207 
physical signs, 210 
purulent, 208 
putrid, 209 
Bronchoblenorrhea, 208 
Bronchopneumonia, 240 
diagnosis, 244 

differential from acute bronchi- 
tis, 244 
lobar pneumonia, 244 
meningitis, 245 
phthisis, 242 
disseminated, 242 

jDathology, clinical, 240 
physical signs, 242 
pseudolobar, 242 
pulse in, 242 
syphilitic, 267 
Bronchopneumonic phthisis, acute, 254 
Bronchorrhea serosa, 209 
Bronchostenosis, 224 (see Tracheo- 
bronchial stenosis) 
Bronchial breathing, 148 
pathological, 153 
physiological, 148 
Bronchovesicular breathing, 148 
pathological, 154 
physiological, 148 
Bronchus, left, 33 
primary, 37 
right, 34 
Broadbent's sign, 333 
Bruit de diable, 395 
de drapeau, 162 

in fibrinous bronchitis, 214 



Bruit— Cont 'd. 

de galop, 371 

de pot fele, 142 
Buccal cavity, examination of, 626 
Bulging, local of abdomen, 509 
of thorax, 70 

precordial, 327 

unilateral, of thorax, 70 
Bundle, of His, 321, 373 
Bursitis, prepatellar, 653 
Button-hole mitral defect, 453 



Calculus, pancreatic, 525 
Calves, swelling of, 651 
Cancrum oris, 620, 626 
Canities, 602 
Canter-rhythm, 371 
Capillaries, pulmonary, 38 
Capillary pulse, 341, 636 

in aortic regurgitation, 341 
Caput medusae, 496 
Carcinoma, of iDone, 185 

of common duct, 525 

of gall bladder, 555 

of kidney, 593 

of liver, 559 

of lung, 295 

of pancreas, 547 

of spleen, 573 

of stomach, 525 
Cardiac, (see Heart) 

impulse, 334, 346 (see Impulse, car- 
diac) 
Cardiohepatic angle of Ebstein, 121, 
360 

dullness of, 130 
Cardiorespiratory murmur, 392 
Caries, vertebral, 70 
Carotid artery, examination of, 394 

murmur in, 394 

pulsation of, 329 
Catarrhe sec of Laennec, 208, 209 

pituiteux, 209 
Catarrhal pneumonia, 240 (see Bron- 
chopneumonia) 
Cavernous respiration, 153 

voice, 158 
Cavity, abdominal, 485 

bronchiectatic, 215 

buccal, 626 
color, 626 
dryness, 626 

eruptions, 626 
moisture, 626 
mucous patch, 626 
noma, 626 

laryngeal, 32 

pleural, 29 

pulmonary, 250 

thoracic, 28 



710 



INDEX 



Cavity, thoracic — Cont 'd. 
capacity of, 28 
divisions of, 29 
limits of, 28 
tuberculous, 250 
Cecum, clinical anatomy, 535 

palpation of, 538 
Cells, heart-failure, 228 

mastoid, inflammation of, 601 

radiography of, 187 
Purkinje, 374 
Central pneumonia, 234, 237 
Centripetal venous pulse, 333 
Cervical glands, enlargement, 633 
veins, diastolic collapse, 331 
engorgement, 331 
pulsation, 331 
Chalazion, 612 
Chalicosis, 269 
Chalk-stones, 640 
Chancre, of eyelid, 612 

of lip, 617 
Charcot-Leyden crystals, 219 
Charcot's joint, 652 
Chest, barrel, 60 

clinical anatomy, 25 (see Thorax) 
funnel, 68 
wall, 25, 28 
Clieyne- Stokes respiration, 78 
Chloasma, 609 
Chlorosis rubra, 609 
Cholecystitis, 561 

point of tenderness in, 561 
Cholelithiasis, 561, 568 

point of tenderness in, 561 
Chordtfi tendinese, 319 
sclerosis of, 321 
shortening of, 321 
Chorea, gravidarum, 648 
hemiparalytic, 648 
Sydenham's, 603, 648 
Chronic adhesive pericarditis, 413 
(see Pericarditis, adhe- 
sive, chronic) 
bronchitis, 207, (see Bronchitis, 

chronic) 
endocarditis, 421 (see Endocarditis, 

chronic) 
interstitial pneumonia, 245 (see In- 
terstitial pneumonia, chron- 

myocarditis, 469 (see Myocarditis, 

chronic) 
ulcerative phthisis, 255 
advanced, 260 
cavities in, 257 
diagnosis, 263 

differential from bronchiecta- 
sis, 264 
lobar pneumonia, 264 
malaria, 263 



Chronic ufcerative phthisis — Cont 'd. 
pulmonary abscess, 264 
gangrene, 264 
hemoptysis in, 260 
incipient, 258 
Lorenz 's sign, 260 
pathology, clinical, 255 
physical signs, 257 
pneumothorax in, 257 
pulse in, 261 
Rothschild's sign, 260 
sputum in, 261 
thorax of, 258 
valvular disease, 423 
Circulatory organs, clinical anatomy, 
317 
diseases of, 407 
examination of, 317 
Cirrhosis, of liver, 565, 566 
atrophic, 565 
Hanot 's, 566 
hypertrophic, 566 
of lung, 245 

after bronchopneumonia, 246 
after lobar pneumonia, 246 
pleurogenous, 246 
Claudication, intermittent, 654 
Clavicle, as landmark of thorax, 44 

elevation of, 63 
Clavicular line, 47 
Claw-hand, 643 
Cleft-palate, 620 
Click, mucous, 163 
Clonus, ankle, 671 

patellar, 672 
Clubbed fingers, 641 
Club-foot, 651 
Coal miner's disease, 270 
Cog-wheel respiration, 154, 262 

in phthisis, 154, 262 
Coin test, Gairdner's, 144 
Colic, hepatic, 525 
Collapse, diastolic, of jugulars, 331 

pulmonary, 272 
Colon, ascending, 536 
clinical anatomy, 536 
descending, 537 
palpation of, 538 
transverse, 537 
Colonic tympany, 542 
Color changes, of abdomen, 496 

of thorax, 53 
Color-blindness, 675 
Holmgren test, 675 
Thomson test, 675 
Columnae carneae, 319 
Compensation, of heart, 424 

broken, 424 
Compensatory emphysema, 279 (see 
E m p h y s ema, compensa- 
tory) 



INDEX 



711 



Compensatory emphysema — Cont 'd. 

pause, 373 
Complementary sinus, 41 
Congenital heart disease, 479 {see 
Heart disease, congenital) 

syphilis, 266 
Congestion, of lungs, 226 

collateral, 226 

diagnosis, 227 

hypostatic, 226 

mechanical, 226 

pathology, clinical, 226 

physical signs, 227 

pulmonary, 226 
Conjunctiva, cyanosis, 612 

examination of, 612 

hemorrhage, 612 

pallor, 612 

yellowness, 612 
Conjunctivitis, 612 
Consonating rales, 162 
Contour, of abdomen, 501 
Contracture, Dupuytren 's, 644 

hcmiplegic, 644 

of arm, 647 
Contraction, local, of thorax, 72 

unilateral, of thorax, 70 
Conus arteriosus, 319 

narrowing of, 479 
Convulsive tic, 610 
Cook's sphygmomanometer, 397 
Coprolalia, 610 
Cor biloculare, 479 

bovinum, 472 

triloculare, 479 

villosum, 408 . 
Cords, vocal, 33 
Cornea, opacity, 614 

ulceration, 614 
Corona veneris, 611 
Coronary arteries, 317 

ligament, 551 
Corrigan button-hole orifice, 434 

pulse, 357, 432 
Corrigan 's disease, 425 
Corset liver, 552 
Costal angle, 57, 61, 64 

arch, 486 

cartilages, 56 

line, sixth, 47 
third, 47 

pleura, 29 

respiration, 74 
Costoabdominal respiration, 74 
Costoarticular line, 570 
Costovertebral angle, 588 
Cough, of aortic aneurysm, 211 
Crachats perles, of Laennec, 208 
Cracked-pot sound, 142 

in bronchiectasis, 142, 143 
phthisis, 262 



Cracked-pot sound in — Cont 'd. 
serofibrinous pleurisy, 303 
Craniotabes, 599, 601 
Cranial nerves, examination of, 673 
Crepitant rale, 162 
Crepitation, 105 

gallstone, 563 
Crepitus indux, 163 

redux, 163 
Crest, iliac, 487 
Cretinism, 600, 605 

facies of, 605 

head of, 600 
Cricoclavicular line, 46 
Croupous pneumonia, 232 {see Lobar 

pneumonia) 
Curschmann's spirals, 219 
Curve, Ellis', 305 
Cyanosis, 81, 609, 616 

general, 81 

local, 81, 82 
Cycle, cardiac, 372 
Cyrtometer, 173 
Cyrtometry, 173 
Cyst, blood, 625 

branchial, 635 

echinococcus, of liver, 559 
of lung, 105 
of kidney, 593 

lingual, 625 

Meibomian, 612 

mucous, 625 

of auricle, 604 

of bone, 185 

of pancreas, 547 

ovarian, 547 

sebaceous, 604 

D 

Dactylitis, 641 
Deafness, nerve, 684 

middle ear, 684 
Decubitus, in bronchiectasis, 217 

in lobar pneumonia, 234 

in pulmonary abscess, 286 

in pulmonary gangrene, 292 

in serofibrinous pleurisy, 301 

right lateral, 579 
Deformity, of spine, 69 

of thorax, 59 
Degeneration, myocardial, acute, 467 
Deglutition pneumonia, 240 

sound, 532 
Delirium cordis, 379 
Dentition, delayed, 620 

premature, 620 
Diabetes mellitus, breath in, 620 
Diagnosis, radiographic, 176 
Diaphragm, 28, 191 

movements of, 191 



712 



INDEX 



Diaphragm — ^Cont 'd. 
pelvic, 485 
radiography of, 191 
Diaphragmatic phenomenon, 75 
abolition of, 76 
pleura, 30 
XDleurisy, 306 
Diastasis, of recti, 522, 534 
Diastolic collapse, jugular, 331 
murmurs, 382 
aortic, 386 
pulmonary, 390 
pressure, 397 
Diathesis, gouty, 209 
Dicrotic notch, 349 
pulse, 349 
wave, 349 
Dilatation, auricular, left, 476, 478 
right, 476, 478 
bronchial, 214 
cardiac, 474 
diagnosis, 478 

differential, 478 
pathology, clinical, 474 
physical signs, 476 
ventricular, left, 476 

right, 476 
with hypertrophy, 475 
with thinning, 475 
Diplegia, 662 
Diphtheria, nasal, 615 
Disease, Addison's, 609 
Banti's, 566 
congenital, of heart, 478 
Corrigan 's, 425 
Hodgkin's, 573, 634 
Little's, 660 
Morvan's, 641 
Paget 's, 655 
Pott's, 634 
Eaynaud's, 641 
Stokes-Adams, 377 
valvular, chronic, 423 
Woillez's, 239 
Diseases, of bronchi, 205 
of circulatory organs, 407 
of endocardium, 418 
of lungs, 232 
of myocardium, 418 
of pericardium, 407 
of pleura, 297 
of respiratory organs, 205 
Displaced kidney, 588 
Dittrich's plugs, 209 
Diverticulum, esophageal, 270 
Double murmur of Duroziez, 395 

pneumonia, 234 
Dry rales, 159 
Duct, common, 553 
cystic, 553 
hepatic, 553 



Dullness, 1^ 
at apices, 129 
at bases, 129 
cardiac, area of, 359 

relative, 126, 359 

absolute, 130, 359 

displacement of, 362 

general decrease, 362 
increase, 362 

increase to left, 363 
to right, 363 

upward increase, 363 

variations in, 361 
hepatic, 563 

absence of, 564 

decrease of, 565 

increase of, 566 
in bronchopneumonia, 243 
in cardiohepatic angle, 130 
in chronic bronchitis, 210 
in chronic interstitial pneumonia, 

248 
in chronic ulcerative phthisis, 129 
in lobar pneumonia, 129 
in pulmonary edema, 129 
in serofibrinous pleurisy, 129 
of lung, 130 
scapular, 129 

over Traube 's semilunar space, 130 
paravertebral, 129 
sloping, 535 
sternal, 129 

unilateral, of thorax, 129 
vascular, 365 
Duodenojejunal flexure, 533 
Duodenum, clinical anatomy, 533 
Dupuytren 's contracture, 644 
Duration, of percussion sound, 118 

of pulse, 356 
Duroziez 's sign, 395 

in aortic regurgitation, 395 
Dyspnea, 79 
anemic, 81 
cardiac, 80 
expiratory, 79 
hemic, 80 
inspiratory, 79 
in atelectasis, 273 

bronchial asthma, 80, 221 

bronchopneumonia, 242 

chronic adhesive pleurisy, 312 

emphysema, hypertrophic, 276 

phthisis, 261 

pulmonary congestion, 227 
edema, 228 
toxemic, 80 

E 

Ear, congenital defects, 603 
cyanosis, 604 
cysts, 604 



INDEX 



713 



Ear— Cont 'cl. 

discharge from, 604 
examination of, 603 
hematoma, 604 
keloid, 604 
otomycosis, 604 
tophi, 604 
Ebstein's cardiohepatic angle, 121, 
360 
dullness of, 130 
Echinococcus cyst, of kidney, 593 
of liver, 559 
lung, 105 
Echolalia, 610 
Edema, angioneurotic, 617 
of eyelids, 611 
of forearm, 647 
of glottis, 33 
of lungs, 227 
acute, 227 
chronic, 228 
diagnosis, 229 
general, 227 
local, 227 

pathology, clinical, 227 
physical signs, 228 
of thigh, 653 
of thorax, 55 
Effects of valvular lesions, 423 
Effusion, pericardial, 410 

pleural, 299 
Egophony, 158 

in lobar pneumonia, 158 

serofibrinous pleurisy, 158, 304 
Elbow, miner's, 649 
Ellis' curve, 305^ 
Embolic abscess of lung, 286 

gangrene of lung, 290 
Embryocardia, 379 
Emphysema, acute vesicular, 281 
pathology, clinical, 281 
physical signs, 282 
atrophic, 278 
diagnosis, 279 
pathology, clinical, 278 
physical signs, 279 
thorax of, 278 
chronic, 274 
compensatory, 279 
diagnosis, 281 
pathology, clinical, 279 
physical signs, 280 
diffuse, 274 
hypertrophic, 274 
diagnosis, 278 

differential, 278 
Freund's theory of, 275 
pathology, clinical, 274 
physical signs, 276 
thorax of, 60 
idiopathic, 274 



Emphysema — Cont 'd. 

interstitial, 282 

pathology, clinical, 282 
physical signs, 283 

large-lunged of Jenner, 274 

pulmonary, 274 

substantive, 274 

thorax of, 60, 276 
Emphysematous crackling, 283 

thorax, 60 
Empyema, 308 

diagnosis, 311 

local edema in, 55, 310 

necessitatis, 55, 85, 108, 310 

pathology, clinical, 308 

physical signs, 310 

pulsating, 55, 108, 310 
Encysted pleurisy, 307 
Endocardial murmurs, 380 (see Mur- 
murs, endocardial) 
Endocarditis, acute, 418 

chronic, 421 

pathology, clinical, 421 
physical signs, 422 

diagnosis, 420 
differential, 421 

pathology, clinical, 418 

physical signs, 420 

infective, 418 

malignant, 418 

mural, 418 

recurrent, 418 

simple, 418 

valvular, 418 
Endocardium, 318 

diseases of, 418 
Endothelioma, pulmonary, 295 
Enophthalmos, 613 
Ensiform cartilage, 486 
Enterolith, 534 
Enteroptosis, 506 

abdominal contour in, 506 
Eosinophilic bronchitis, 210 
Epicardium, 318 

Epigastric artery, surface markings, 
489 

pulsation, 330 

region, 492 
Epigastrium, bulging, 522 

pulsation, 330 
diastolic, 330 
systolic, 330 

retraction, 506 
Epilepsy, Jacksonian, 662 
Episternal notch, 44 
Epithelioma, of eyelid, 612 

of lip, 618 
Epithelium, respiratory, 37 
Epistaxis, 615 
Epulis, 621 
Erlanger's sphygmomanometer, 399 



714 



INDEX 



Erythema nodosum, 647, 651 

solar, 646 
Erytliromelalgia, 651 
Essential tachycardia, 375 
Ewart's sign, 411 
Excrescences, of cardiac valves, 419 

verrucose, 419 
Excursion, inspiratory, of abdomen, 
75 
of thorax, 72 

respiratory, of lung, 125 
Exophthalmic goiter, 610, 612, 632 
Exophthalmos, 612 
Exostosis, 185 
Expansion of thorax, 82 

wavy, 84 
Expiration, prolonged, 77 
Exploratory puncture, 174 
Extrasystole, 378 

auricular, 379 

auriculoventricular, 379 

ventricular, 379 
Eyelid, chancre, 612 

duskiness, 611 

edema, 611 

epithelioma, 612 

ptosis, 611 

xanthoma, 611 
Eyes, conjugate deviation of, 613, 
'680 

examination of, 611 



Pace, bluish discoloration, 609 
brown patches, 609 
color, 609 
contour of, 605 

in acromegaly, 605 
in cretinism, 605 
in hydrocephalus, 605 
in leontiasis ossium, 608 
in leprosy, 608 
in myxedema, 605 
in osteitis deformans, 605 
cyanosis, 609 
examination of, 605 
flushing, 609 
pallor, 609 

yellow discoloration, 609 
Facies, emphysematous, 276 

leontina, 608 
Falciform ligament, 549 
Falling- drop sound, 167 
Fascia, Sibsen's, 28 
Fat wave, 514 

Faught 's sphygmomanometer, 403 
Fecal impaction, 542 
Femoral artery, double murmur in, 

395 
Fcstinating gait, 661 



Fetus, pneiWonia alba of, 266 
Fibrillation, auricular, 379 
Fibrinous bronchitis, 212 

acute, 213 

diagnosis, 214 

idiopathic, 213 

pathology, clinical, 212 

physical signs, 213 

pericarditis, acute, 407 

pleurisy, acute, 297 
Fibroid phthisis, 264 

diagnosis, 266 

pathology, clinical, 264 

physical signs, 265 
Fibrosis, pulmonary, 245 
Finger percussion, 112 
Fingers, clubbed, 480, 641 

distortions, 641 

enlarged joints, 640 

Heberden's nodes, 640 

Hippocratic, 480, 641 

Morvan 's disease, 641 

Eaynaud's disease, 641 

tophi, 638 
Fissures, of lungs, 35, 42 
Fistula, branchial, 635 

pulmonary, 257 

sound, lung, 171 
Flat-foot, 650 
Flatness, 130 

cardiac, area of, 359 

hepatic, area of, 563 

of Ebstein's angle, 130 

of Traube 's semilunar space, 130 
Flexion folds of abdomen, 489 
Flexure, duodenojejunal, 533 

hepatic, 536 

sigmoid, 537 

splenic, 537 
Flicking percussion, 516 
Flint murmur, 384 
Floating kidney, 588 

liver, 564 

spleen, 577 
Fluctuation, abdominal, 513 

in thoracic disease, 109 

of kidney, 593 
Fluid veins, 380 

wave, 513 
Fluoroscopy, 176 
Fontanelles, 600 

bulging, 600 

depression, 600 

enlargement, 600 

tardy closure, 600 
Foot, club, 651 

enlargement, 651 

examination of, 650 

flat, 650 
I'oramen ovale, 318 

patent, 318, 479 



INDEX 



715 



Force, of percussion, 117 

of pulse, 354 
Forearm, edema, 647 

epiphyseal enlargement, 647 
erythema nodosum, 647 
examination of, 647 
Forehead, eruptions, 611 

examination of, 611 
Fossa, infraclavicular, 44 
bulging of, 63 
retraction of, 63 
ovalis, 318 
supraclavicular, 44 
bulging of, 63 
retraction of, 63 
Fremitus, friction, pericardial, 344 
peritoneal, 516, 577 
pleural, 103, 298 
rhonchal, 102 
hydatid, 105 
succussion, 104 
tussile, 104 
vocal, 89 
absent, 101 
decreased, 99 
increased, 98 
intensity of, 91 
normal variations, 94 
Friction, abdominal, 577 
fremitus, pleural, 103 

in acute fibrinous pleurisy, 298 
pericardial, 344, 393, 409 
pleuropericardial, 298, 410 
perihepatitic, 516 
pleural, 169, 170, 298 
pericardial, 393 

perisplenic, '516, 577 
sound, 169, 170 
Friedreich's sign, 331 

in chronic adhesive pericarditis, 
331 
respiratory change of sound, 137 
Frostbite, 604 

Functional murmurs, 390 {see Mur- 
murs, functional) 
Funnel chest, 68 

G 

Gairdner 's coin test, 144 
Gait, 659 

ataxic, 660 

cerebellar, 661 

festinating, 661 

hemiplegic, 659 

spastic, 659 

steppage, 660 

vertiginous, 661 
Gall bladder, clinical anatomy, 549 

crepitations, 563 

examination of, 556 

inspection of, 556 



Gall bladder— Cont 'd. 

palpation of, 562 

surface markings, 549 
Galloping consumption, 254 
Gallop-rhythm, 371 
Gallstone crepitus, 563 
Ganglion, 644 
Gangrene, of fingers, 641 

of lung, 289 

after lobar pneumonia, 234 
circumscribed, 290 
diagnosis, 294 
diffuse, 290 

pathology, clinical, 289 
physical signs, 292 
sputum in, 292 

of toes, 650 
Gastrectasis, 522 
Gastritis, acute, 525 
Gastrodiaphany, 524 
Gastroptosis, 506, 522 

abdominal contour in, 506 
Geographical tongue, 624 
Gerhardt's change of sound, 138 
Gland, Blandin-Nuhn's, 625 

mammary, 45 

as landmark of thorax, 45 
hypertrophy of, 55 

thyroid, 631 

palpation of, 631 
Glands, enlarged, cervical, 632 

epitrochlear, 638 

inguinal, 498 

occipital, 633 

parotid, 633 

submaxillary, 632 

supraclavicular, 634 

tracheobronchial, 30, 34 
Glandular enlargement, 632 
Glenard's belt sign, 526 
Globe, of eye, 612 

position of, 613 
Goiter, cystic, 632 

exophthalmic, 610, 612, 632 

fibrous, 631 
Gout, toe of, 650 

tophi of, 604, 638 
Grinder's rot, 271 
Grocco 's sign, 129 

in purulent pleurisy, 311 
serofibrinous pleurisy, 129 
Groove, Harrison's, 67 
Gumma ^ pulmonary, 267 
Gums, blue line, 621 

examination of, 621 

in copper poisoning, 621 

in mercurial poisoning, 621 

in pellagra, 621 

in plumbism, 621 

in pyorrhea alveolaris, 621 

in scorbutus, 621 



716 



INDEX 



Gums — Cont 'cl. 

in ulcerative stomatitis, 621 

red line, 621 

sponginess, 621 

tumor, 621 
Gurgling, in hourglass stomach, 532 

rales, 164 
Gutta cadens, 167 



Habit spasm, 610 
Hair, color, 602 

crepitus, 147 

falling, circumscribed, 601 
general, 601 
Hand, accoucheur's, 644 

ape, 644 

claw, 643 

examination of, 636 

hemiplegic, 643 

seal-fin, 644 

shape, 641 

spade, 641 

tremor of, 644 
Hare-lip, 620 
Harrison's sulcus, 67 
Haygarth's nodosities, 640 
Head, bones, 600 

cretinoid, 600 

deviation, lateral, 602 

examination of, 599 

fixation, 602 • 

fontanelles, 600 

hydrocephalic, 600 

movements, 603 

position, 602 

rachitic, 599 

radiography, 187 

shape, 599 

size, 599 

sutures, 600 
Heart, 317 

aneurysm, 468 

apex of, 317, 325 
displacement of, 336 
site of, 334 
thrill at, 345 

arrhythmia, 372 
clinical types, 374 

atrophy, 337 

auricles, 318 

auscultation, 366 

automaticity, 372 

base, 317, 324 
pulsation at, 328 
thrill at, 345 

beat, myogenic, 373 
neurogenic, 373 

block, arrhythmia, 378 
complete, 378 



Heart block^Cont 'd. 
partial, 378 
borders, 317, 324, 325 
conductivity, 372 
cycle, 372 

dilatation, 474 (see Dilatation, car- 
diac) 
disease, congenital, 478 
diagnosis, 480 
pathology, clinical, 478 
physical signs, 480 
dullness, area of, 359 
decreased, 363 
displaced, 362 
increased, 362 
extrasystole of, 378 
failure cells, 228 
flatness, area of, 359 
hypertrophy, 470 (see Hypertro- 
phy, cardiac) 
impulse, 334, 346 
irritability, 373 
nerve sui^ply, 374 
palpation, 343 
palpitation, 376 
rapid, 375 
rhythmicity, 373 
slow, 376 
sounds, 366 

accentuation of, 368 
adventitious, 380 
diminution of, 368 
duration of, 372 
equalization of, 380 
fetal, 518 
first, 366, 369 

accentuation of, 369 

enfeeblement of, 369 

reduplication of, 371 

in acute myocarditis, 468 

in aortic regurgitation, 433 

stenosis, 440 
in cardiac dilatation, 477 

hypertrophy, 474 
in chronic adhesive pericarditis, 
415 
myocarditis, 470 
in lobar pneumonia, 236 
in mitral regurgitation, 449 

stenosis, 455 
in pulmonary regurgitation, 458 

stenosis, 461 
in serofibrinous pericarditis, 412 
in tricuspid regurgitation, 464 

stenosis, 465 
intensity of, 368 
reduplication of, 371 
second, 366, 369, 370 
accentuation of, 369 
enfeeblement of, 370 
reduplication of, 371 



INDEX 



717 



Heart— Cont 'd. 

surface markings, 324 
tonicity, 372 
valves, 320, 326 
ventricles, 319 
Heberden's nodes, 640 
Hematoma auris, 604 
Hemeralopia, 675 
Hemianopia, 677 
homon}anous, 677 
heteronymous, 677 
nasal, 677 
temporal, 677 
Hemiatrophy, facial, 608 
Hemic murmurs, 390 
Hemichorea, 662 
Hemihypertrophy, facial, 609 
Hemiplegia, 643, 662 
contractures in, 643 
gait in, 659 
hand in, 643 
Hemopericardium, 416 
pathology, clinical, 416 
physical signs, 416 
Hemopneumothorax, 314 
Hemoptysis, in Ijronchiectasis, 216 
in phthisis, 261 
in pulmonary gangrene, 230 
infarction, 230 
syphilis, 268 
Hemorrhage, in phthisis, 257 

internal, signs of, 313 
Hemorrhagic infarction, of lung, 229 
Hemothorax, 313 

pathology, clinical, 313 
physical signs, 313 
Hepatic pulsation, 329 
Hepatization, gray of lung, 233 

red, of lung, 232 
Hepatoptosis, 568 
Hernia, diaphragmatic, 337 
femoral, 655 
umbilical, 497 
Herpes labialis, 239, 617 

in lobar pneumonia, 239 
Hippocratic fingers, 641 
succussion sound, 168 
Hippus, 679 

His, bundle of, 321, 373 
Hissing respiration, 78 
Hodgkin's disease, 573, 634 
Holmgren test, 675 
Hordeolum, 612 
Horseshoe kidney, 586, 594 
Hourglass stomach, 531 
Housemaid's knee, 653 
Hum, venous, 395 
Humming-top murmur, 395 
Hutchinson's teeth, 621 
Hydatid fremitus, 105 
Hydrocephalus, facies of, 605 



Hydronephrosis, 586, 589 

fluctuation in, 593 
Hydropericardium, 416 
pathology, clinical, 416 
physical signs, 416 
Hydropneumothorax, 314 (see Pneu- 
mothorax) 
Hydrops, percardii, 416 
Hydrothorax, 313 

in cardiac disease, 314 
in renal disease, 313 
pathology, clinical, 313 
physical signs, 313 
Hyperosmia, 674 
Hyperresonance, 130 

in compensatory emphysema, 130 

hypertroi)hic emphysema, 130 
local, 130 
pulmonary, 130 
relaxation as cause^ 139, 140 
Hypertension, 356 

Hypertrophic emphysema, 274 (see 
Emphysema, hypertrophic) 
Hvpertrophv, auricular, left, 473 
right, 473 
cardiac, 470 
concentric, 470 
cor bovinum in, 471 
diagnosis, 474 
eccentric, 470 
general, 470 
pathology, clinical, 470 
physical signs, 473 
pulse in, 474 
of nails, 638 
ventricular, left, 472 
right, 473 
Hypochondriac region, 49, 492 
Hypogastric region, 492 

enlargement, 507 
Hypostatic congestion, 226 
Hypotension, 356 



Ileocecal valve, clinical anatomy, 534 
Heum, clinical anatomy, 534 

obstruction of, 534 

ulceration of, 534 
Iliac artery, common, 489 
external, 489 

crest, 487 

region, 492 

spine, 487 
Illumination, direct, 53 

oblique, 53 
Immediate auscultation, 145 

percussion, 112 
Impaction, fecal, 542 
Impaired resonance, 116 
Impulse, bathmotropic, 373 



718 



INDEX 



Impulse — Cont 'd. 
cardiac, 334, 346 
absence, 334 
displacement, 336 
downward, 337 
to left, 337 
to right, 339 
upward, 337 
double, 340 
extent, 339 
force, 340 
site of, 334 
in child, 334 
chronotropic, 374 
dromotropic, 374 
inotropic, 373 
Incisura cardiaca, 40 
Incurvation, of nails, 637 
Infarction, of lungs, 229 

of spleen, 573 
Infective endocarditis, 418 
Infiltration, carcinomatous, of lung, 
295 
purulent, of lung, 286 
Infraaxillary region, 50 
Infraclavicular fossa, 44 

region, 49 
Infrascapular line, 47 

region, 50 
Inguinal adenitis, 654, 

glands, enlarged, 498, 654 
Innominate artery, 358 

aneurysm of, 358 
Inorganic murmurs, 390 
Inspection, of abdomen, 495 
of bladder, 597 
epigastrium, 521 
gall bladder, 553 
intestine, large, 538 

small, 534 
kidneys, 586 
liver, 553 
precordia, 327 
spleen, 572 
stomach, 521 
thorax, 52, 327 
Inspiration, prolonged, 77 
Instrumental estimation of blood 
pressure, 397 
percussion, 112 
Insufficiency, aortic, 425 
mitral, 441 
pulmonary, 457 
tricuspid, 462 
relative, 462 
Intensity, of murmurs, 382 
of percussion sound, 118 
Intention tremor, 644 
Intercostal nerves, 25 

spaces, 44, 55, 61, 64, 84, 107 
as landmark of thorax, 44 



Intercostal spaces — Cont 'd. 
bulging, 55 
narrowing, 55 
retraction, 55, 61, 84 
tenderness, 107 
widening, 55, 61, 64 
muscles, 25 
neuralgia, 299 
Interlobar pleurisy, 307 
Intermission, 353 

false, 375 
Intermittence, 375 
Intermittent claudication, 654 
Interrupted change of sound, Win- 

trich's, 135 
Interscapular region, 50 

contents of, 50 
Interstitial keratitis, 613 
myocarditis, 469 
pneumonia, chronic, 245 
circumscribed, 246 
diagnosis, 248 
diffuse, 246 
insular, 247 
pathology, clinical, 245 
physical signs, 247 
pleurogenous, 246 
Intertubercular line, 491 
Interventricular septum, defects of, 

479 
Intestinal obstruction, 534 

visible peristalsis in, 534 
Intestine, large, clinical anatomy, 
535 
examination of, 538 
small, clinical anatomy, 532 
examination of, 534 
obstruction, 500, 534 
Intussusception, 534 



Janeway's sphygmomanometer, 400 

Jaw-jerk, 671 

Jejunum, clinical anatomy, 534 

Joint, Charcot 's, 652 

Joints, enlarged, of fingers, 640 

Jugular veins, auscultation, 395 

diastolic collapse, 331 

engorgement, 331 

murmur in, 395 

systolic pulsation in, 331 

K 

Keel breast, 68 

in rickets, 68 

tonsillar hypertrophy, 68 
Keloid, 604 

Keratitis, interstitial, 613 
Kernig's sign, 652 
Kidneys, auscultation of, 591 

clinical anatomy, 583 

cyst of, 593 



INDEX 



719 



Kidneys — Cont 'd. 

displaced, 588 

enlarged, 586 

examination of, 586 

fluctuation of, 593 

floating, 588 

horseshoe, 594 

inspection of, 586 

mobility of, 592 

movable, 588 
degrees of, 588 

palpation of, 587 

polycystic, 593 

pulsation of, 594 

sensibility of, 589 

surface markings of, 585 

tumor of, 594 

volume of, 591 
Knee, housemaid's, 653 

jerk, 669 
Knock-knees, rachitic, 655 
Koplik's spots, 626 
Kyphosis, 63, 66, 69 



Laennec's catarrhe sec, 208 
pituiteux, 209 

crachats perles, 208 
Lagophthalmos, 612 
Landmarks, anatomic, of abdomen, 
489 
of thorax, 44 
Laryngeal stenosis, 77, 225 

breathing in, 225 
Larynx, clinical anatomy, 31 

cavity of, 32 

deflection of, 32 

movements of, 631 

obstruction of, 77 

prominence of, 32, 64 
Laryngophony, 155 
Left auricle, clinical anatomy, 318 

ventricle, 319 
Legs, atrophy, 651 

bowing, 651 

examination of, 651 

nodes, 651 

ulcer, 651 

varicose veins, 651 
Leontiasis ossium, facies of, 608 
Leprosy, facies of, 608 
Leukemia, lymphatic, 573 

splenomedullary, 573 
Leukoplakia, 624 
Ligament, coronary, 551 

falciform, 549 

Poupart's, 486 
Ligamentum arteriosum, 323 

latum pulmonis, 36 
Ligneous phlegmon, 635 



Limb, anacrotic, 349 

catacrotic, 349 
Limit, of resonance, 123 

variations in, 123 
Line, axillary, anterior, 46 
posterior, 46 

clavicular, 47 

costal, sixth, 47 
third, 47 

costoarticular, 570 

cricoclavicular, 46 

infrascapular, 47 

intertubercular, 491 

mammary, 46 

midaxillary, 46 

midclavicular, 46 

mid-Poupart, 491 

midspinal, 46 

midsternal, 46 

nipple, 46 

of transmission of murmurs, 382 

scapular, 46 
spinal, 47 

sternal, 46 

subcostal, 491 

twelfth dorsal, 47 
Linea alba, 489 

nigra, 480, 496 

semilunaris, 488 
Lineae albicantes, 495 

transversae, 489 
Lips, chancre, 617 

cyanosis, 616 

enlargement, 617 

epithelioma, 618 

fissures, 617 

herpes, 617 

mucous patch, 617 

pallor, 616 

parted, 617 

pendulous, 617 

rhagades, 617 
Litten's phenomenon, 75 

absence of, 76 
Liver, abscess of, 566 

amyloid, 560 

areas of dullness and flatness, 563 

atrophy, 559 

auscultation of, 568 

carcinoma of, 559 

clinical anatomy, 549 

consistence of, 560 

corset, 552 

cyst of, 559 

decreased size of, 565 

displacement of, 568 

dullness of, 563 

enlargement of, 558 

flatness of, 563 

floating, 564 

fluctuation of, 560 



720 



INDEX 



Liver — Cont 'cl. 

inspection of, 553 

mobility of, 554, 561 

palpation of, 556 

percussion of, 563 

pulsation of, 563 

Eiedel's lobe, 552 

sensibility of, 560 

surface markings, 553 

syphilis of, 559 

tumors of, 554 
Lobar pneumonia, 232 

abscess of lung after, 234 

apical, 234 

central, 234 

cirrhosis of lung after, 234 

clinical types, 234 

decubitus in, 234 

diagnosis, 236 

differential from acute pneumonic 
phthisis, 238 
bronchopneumonia, 238 
pulmonary congestion, 239 
edema, 239 
infarction, 238 
serofibrinous pleurisy, 239 

distribution. 234 

double, 234 

gangrene of lung after, 234 

heart sounds in, 236 

massive, 234 

pathology, clinical, 232 

physical signs, 234 

pleurisy in, 233 

pulse in, 235 

purulent infiltration in, 286 

rale indux in, 236 
re dux in, 236 

sputum in, 233 

stage of engorgement, 232 
gray hepatization, 233 
red hepatization, 232 
resolution, 233 
Lobe, Riedel's, 552 
Lobes, of lungs, 35, 42 
Lobular pneumonia, 240 {see Bron- 
chopneumonia) 
Local bulging, 70 

pulsation, 85, 108 

retraction, 71 

pleurisy, 306 
Loculated pleurisy, 307 
Lordosis, 45, 66, 69 
Lorenz's sign, 260 
Louis, angle of, 44 
Ludovici, angulus, 44 
Ludwig's angina, 635 
Lumbar region, 492 
Lungs, abscess of, 283 

albinism of, 276 

alveoli of, 38 



Lungs — C»nt 'd. 
apex of, 34 
auscultation of, 145 
base of, 34 
borders, 35, 41 
bronchioles, 37 
capillaries, 38 
carcinoma of, 295 
catarrhal pneumonia, 240 
cavities, tympany in, 262 
circulation of, 38 
circulatory disturbances of, 226 
cirrhosis of, 245 
clinical anatomy of, 34 
collapse of, 272 
congestion of, 226 
costal surfaces of, 35 
diseases of, 232 
dullness of, 128 
edema of, 227 
emphysema of, 282 
endothelioma of, 295 
excursion of, 36, 125 
fibroid retraction of, 245 
fissures of, 35 
fistula, sound of, 171 
flatness of, 130 
gangrene of, 289 
hepatization of, 232 
hilus of, 35 
induration of, 270 
infarction of, 229 
infundibula of, 38 
inspection of, 52 
ligamentum latum of, 36 
lobes of, 35 
lower borders, 41 
lymphatics of, 35, 39 
mediastinal surfaces, 35 
normal limits of, 41 
palpation of, 86 
pancreatization of, 267 
percussion of. 111 

apices, 115 

auscultatory, 116 

palpatory, 115 
resonance of, 119 
root of, 35 
sarcoma of, 295 
sclerosis of, 270 
splenization of, 241 
surface markings of, 41 
syphilis of, 266 
tuberculosis of, 249 
tumors of, 295 

primary, 295 

secondary, 296 
tympany of, 130 
Lymphatics, pulmonary, 39 
Lymph nodes, mediastinal, 39 
pulmonary 39 
tracheobronchial, 30, 39 



INDEX 



721 



M 

Macrochcilia, 617 
Maeroglossia, 621 
Macrotia, 603 
Main-en-griffe, 643 
Malignant endocarditis, 418 
diagnosis, 421 
physical signs, 420 
Mai perforante, 650 
Mammary gland, 45 

as landmark of thorax, 45 
hypertrophy of, 55 
line, 48 
region, 49 

contents of, 49 
Manubrium sterni, 30 
Mastoid tenderness, 601 
McBurney's point, 539 
Mechanical bronchitis, 207 
Mediastinal glands, 39 

pleura, 30 
Mediastinopericarditis, 270, 413 
Mediastinum, 29 
anterior, 30 

contents of, 31 
middle, 30 

contents of, 31 
posterior, 30 

contents of, 31 
superior, 30 

contents of, 30 
Mediate auscultation, 146 
percussion, 112 

rules governing, 112, 113 
Megalonychosis, 638 
Mensuration, of abdomen, 518 

of thorax, 173 
Metallic tinkle, 167 
Meteorism, 503 

abdominal contour in, 503 
Microtia, 603 
Midaxillary line, 46 
Midclavicular line, 46 
Mid-Poupart line, 491 
Midspinal line, 46 
Midsternal line, 46 
Miliary tubercle, 250 
tuberculosis, acute, 251 
diagnosis, 252 
pathology, clinical, 251 
physical signs, 251 
Millstone maker 's phthisis, 271 
Miner's elbow, 649 
Mitral area, 367 
insufficiency, 441 
incompetence, 441 
murmurs, 383 
presystolic, 383 
systolic, 384 
regurgitation, 441 
diagnosis, 449 



Mitral regurgitation — ^Cont 'd. 
differential, 450 
pathology, clinical, 441 
physical signs, 445 
pulm.onary sound in, 449 
pulse in, 447 
relative, 442 
sourd, accentuation of, 369 

diminution of, 369 
stenosis, 451 

buttonhole orifice in, 451 
diagnosis, 455 

diifeicntial, 455 
pathology, clinical, 451 
physical signs, 453 
pulse in, 454 
thrill in, 454 
valve, 320 

anatomical site, 367 
auscultatory area, 367 
Moist rales, 159, 162 
Monaural stethoscope, 145 
Money-chink resonance, 142 
i\Ionoplegia, 661 
Morbus ceruleus, 480 
Morvan 's disease, 641 
Movable kidney, 588 
Macous click, 163 
patch, 617, 626 
rales, 163 
Multiple murmurs, 391 

sclerosis, tremor of, 644 
Mural endocarditis, 418 
Murmurs, accidental, 390 
aortic, 384 
diastolic, 386 
systolic, 385 
arterial, 394 
diastolic, 394 
systolic, 394 
cardiorespiratory, 392 
diastolic, 382 

double, in aortic regurgitation, 434 
Duroziez 's, 395 
endocardial, 380 
Flint, 384 
functional, 390 

differentiated from organic, 391 
relative incidence of, 391 
generation of, 380 
hemic, 390 
humming-top, 395 
inorganic, 390 
intensity of, 381 
line of transmission of, 382 
mitral, 383 

presystolic, 383 
systolic, 384 
multiple, 391 

separation of, 392 
nun 's, 395 



722 



INDEX 



Murmurs — Cont 'd. 
organic, 380 

point of maximum intensity of, 381 
presystolic, 382 
properties of, 381 
pulmonary, 389 
diastolic, 390 
systolic, 389 
quality of, 382 
safety-valve, 462 
systolic, 382 
time of, 382 
tricuspid, 387 
presystolic, 388 
systolic, 388 
vascular, 394 
venous, 395 
Muscles, papillary, 319 
Musculature, of thorax, 54 

wasting of, 54 
Mydriasis, irritative, 680 

paralytic, 680 
Myocarditis, acute, 467 
diagnosis, 468 
interstitial, 467 
nonsuppurative, 467 
parenchymatous, 467 
pathology, clinical, 467 
physical signs, 468 
suppurative, 467 
chronic, 469 
diagnosis, 470 
fibrous, 469 
interstitial, 469 
pathology, clinical, 469 
physical signs, 470 
Myocardium, 318 
diseases of, 467 
properties of, 372 
Myoidema, 262 
Myomalacia cordis, 469 
Myosis, irritative, 680 

paralytic, 680 
Myotonia congenita, 622 
Myxedema, 601, 605, 632 
facies of, 605 
foot of, 651 
hand of, 641 
head of, 600 

N 

Nails, arrested growth, 638 
atrophy, 638 
brittleness, 638 
capillary pulse, 636 
cyanosis, 636 
examination of, 636 
grooves, 636 
hypertrophy, 638 



Nails — ConVd. 

incurvation, 637 

indolent sore, 638 

pallor, 636 

paronychia, 638 

ridges, 637 

spots, 636 
Neck, elongation, 629 

examination of, 629 

sears, 635 

shape, 629 

short, 629 
Neoplasms, pulmonary, 295 
Nerve, abducent, examination of, 678 

auditory, examination of, 684 

facial, examination of, 682 

glossopharyngeal, examination of, 
696 

hypoglossal, examination of, 697 

oculomotor, examination of, 678 

olfactory, examination of, 673 

optic, examination of, 674 

pneumogastric, examination of, 696 

spinal accessory, examination of, 
697 

trigeminal examination of, 681 

trochlear, examination of, 678 
Nerves, intercostal, 25 
Nervous system, examination of, 657 
Neuralgia, intercostal, 299 
Neurone, motor, lower, 657 
upper, 657 

sensory, 658 
Nipple, as landmark of thorax, 45 
Nodding spasm, 603 
Node, sinoauricular, 321 

of Tawara, 379 
Nodes, bronchial, 30, 39 

Heberden's, 640 

inguinal, enlarged, 498 

tracheobronchial, 30, 34 
Nodosities, Haygarth's, 640 
Noma, 620, 626 
Nose, examination of, 614 

pseudomembrane of, 615 

redness of, 614 

saddle, 614 

shape of, 614 

ulceration of, 615 
Notch, dicrotic, 349 

episternal, 44 

pulsation in, 329 

suprasternal, 44 

umbilical, 549 
Nun's murmur, 395 
Nyctalopia, 675 
Nystagmus, 680, 685, 688 

aural, 680 

induced, 688 

spontaneous, 685 



INDEX 



^23 



O 

Obesitj^, abdominal contour in, 501 
Obturation atelectasis, 224 
Occipital glands, enlarged, 633 
Oculocardiac reflex, 613 
Oligopnea, 77 

Oliver's estimation of venous pres- 
sure, 406 

sign, 34, 483, 631 
Onycliogryposis, 638 
Onychia, 638 
Opacity, corneal, 614 
Orifice, aortic, 322 

auriculoventricular, 319 

cardiac, 520 

23yloric, 520 
Orthopnea, 81 
Osteal resonance, 121 
Osteitis deformans, 655 

facies of, 605 
Osteoarthropathy, pulmonary, 641, 

655 
Osteoma, 185 
Osteomalacia, 655 
Osteomyelitis, 185 
Osteosarcoma, 185 
Othematoma, 604 
Otitis media, 604 
Otomycosis, 604 
Ovarian cyst, 547 



Paget 's disease, 655 
Palate, cleft, 620 

paralysis of, 627 

perforation of, 627 
Palpation, of abdomen, 511 

of bladder, 597 

of cardiac impulse, 346 

of epigastrium, 524 

of gall bladder, 562 

of intestine, large, 538 
small, 534 

of kidney, 587 

of liver, 556 

of pancreas, 547 

of preeordia, 343 

of siDleen, 574 

of stomach, 524 

of thorax, 86 

of ureter, 598 

technic of, 86 

ulnar, 87 
Palpatory percussion, 115 
Palpitation, 376 
Pancreas, clinical anatomy, 544 

carcinoma of, 547 

cyst of, 547 

examination of, 546 

tumor of, 547 



Pancreatitis, acute, 525 
Pancreatization, of lung, 267 
Papillary muscles, 319 
Paradoxical pulse, 354 

in chronic adhesive pericarditis, 415 
serofibrinous pericarditis, 411 
Paralysis, abducent, 681 

agitans, gait of, 661 
propulsion in, 661 
retropulsion in, 661 
tremor of, 644 

brachial, 647 

bulbar, chronic, 617 

Duchenne-Erb type, 647 

facial, 683 

flaccid, 661 

glosso-labio-laryngeal, 621 

glossopharyngeal, 696 

hypoglossal, 697 

Kulmpke type, 647 

musculospiral, 644 

of leg, 655 

of palate, 627 

of tongue, 622 

pneumogastric, 696 

spastic, 661 

spinal accessory, 697 

trigeminal, 682 

trochlear, 681 
Paralytic thorax, 63 
Paramyoclonus multiplex, 648 
Parasternal line, 46 
Paratyphilitis, 539 
Paravertebral dullness, 129 

Grocco 's triangle of, 129 
Paresis, 613 
Paronychia, 638 
Parosmia, 674 

Paroxysmal tachycardia, 376 
Past-pointing, 686 
Patch, mucous, 617, 626 

smoker's, 624 

salmon, 614 
Patent ductus arteriosus, 479 

foramen ovale, 479 
Pause, compensatory, of heart, 373 
Pectoriloquy, 157 

whispering, 157 
Pectus carinatum, 68 
Pellagra, forearms in, 647 

gums in, 621 

tongue in, 625 
Pelvis, 485 
Percussion, auscultatory, 116 

cardiac, 361 

deep, 117 

finger, 112 

flicking, 516 

force of, 117 

immediate, 112 

instrumental. 112 



724 



INDEX 



Percussion — Cont 'cl. 
of abdomen, 516 
of anterior chest wall, 111 
of axillary region, 111 
of back. 111 
of bladder, 597 
of epigastrium, 527 
of heart, 359, 361 
of intestine, large, 542 

small, 534 
of kidney, 595 
of liver, 563 
of lungs. 111 
of precordia, 359 
of spleen, 578 
of stomach, 527 
of thorax. 111, 359 
palpatory, 115 
respiratory, 117 
scratching, 529 
sense of resistance in, 117 
sound, 118 

abnormal, 126 

amphoric, 141 

attributes of, 118 

cracked-pot, 142 

dull, 128 

duration of, 118 

flat, 130 

hyperresonant, 130 

impaired, 126 

intensity of, 118 

normal, 119 

pitch of, 118 

quality of, 118 

resonant, 119 

Skodaic, 139 

special, 130 

tympanitic, 130 
superficial, 117 
Pericardial friction, 393 

fremitus, 344 
succussion, 393 
Pericarditis, 407 

adhesive, chronic, 413 

Broadbent 's sign in, 414 

diagnosis, 415 

Friedreich 's sign in, 414 

Kussmaul's sign in, 414 

pathology, clinical, 413 

physical signs, 414 
clinical types, 407 
external, 413 
exudativa, 410 
fibrinous, acute, 407 

diagnosis, 409 
differential, 409 

pathology, clinical, 407 

physical signs, 408 
internal, 413 
primary, 407 



Pericarditis»— Cont 'd. 
secondary, 407 
serofibrinous, 410 

Auenbrugger's sign in, 411 
Bamberger 's sign in, 412 
diagnosis, 412 

differential, 412 
Ewert's sign in, 411 
milk spots in, 410 
pathology, clinical, 410 
physical signs, 410 
pulse in, 411 
Botch's sign in, 411 
sicca, 407 
with effusion, 410 
Pericardium, clinical anatomy, 321 

diseases of, 407 
Perichondritis, of auricle, 604 
Perihepatitic friction, 516, 568 
Perilymphadenitis, bronchial, 270 
Perinephritic abscess, 594 
Period, refractory, of heart, 373 
Perisplenitic friction, 516, 577 
Perisplenitis, 516, 577 

peritoneal friction in, 516, 577 
Peristalsis, visible, of intestine, 499, 
500, 534 
of stomach, 499, 500, 525 
Peritoneal friction, 516, 568, 577 
in perihepatitis, 516, 568 
in perisplenitis, 516, 577 
in peritonitis, 516 
Peritonitis, acute, 501 

tuberculous, 534 
Perity23hilitis, 539 
Pes planus, 650 
Pharynx, bulging of, 627 
eruptions of, 627 
examination of, 627 
redness of, 627 
ulceration of, 627 
Phenomenon, Biermer 's, 139 
Litten's, 75 
absence of, 76 
Phlegmasia alba dolens, 655 
Phlegmon, ligneous, 635 

AYOody, 635 
Phthisical thorax, 63 
Phthisis, bronchopneumonic, acute, 
254 
chronic ulcerative, 255 (see Cliron- 

ic ulcerative phthisis) 
fibroid, 264 (see Fibroid phthisis) 
florida, 254 
millstone maker's 271 
pneumonic, acute, 252 
stone-cutter 's, 271 
tuberculopneumonic, acute, 252 
Physiologic venous pulse, 332 



INDEX 



725 



Pigeon breast, 68 
cross section of, 68 
in rickets, 68 
Pit, of stomachy 44 
Pitcli, of percussion sound, 118 

of tymj^any, 132 
Plastic pericarditis, 407 

pleurisy, 297 
Plateau, systolic, 350 
Pleura, clinical anatomy, 29 
costal, 29 
diseases of, 297 
diaphragmatic, 30 
mediastinal, 30 
parietal, 28 

surface markings of, 39 
visceral, 30 
Pleural adhesions, 311 

cavity, clinical anatomy, 29 

dropsy of, 313 (see Hydrotho- 
rax) 

effusion into, 299 
friction, 169 

fremitus, 103 
sinus, complementary, 41 
Pleurisy, adhesive, chronic, 311 

diagnosis, 312 

pathology, clinical, 311 

physical signs, 312 
diaphragmatic, 306 

diagnosis, 307 

pathology, clinical, 306 

physical signs, 306 
encysted, 307 
fibrinous, acute, 297 

diagnosis, 299 
differential, 299 

pathology, clinical, 297 

physical signs, 298 
interlobar, 307 

diagnosis, 308 

pathology, clinical, 307 

physical signs, 308 
local, 306 
loculated, 307 

pathology, clinical, 307 

physical signs, 307 
plastic, 297 
purulent, 308 

Baccelli's sign in, 157 

diagnosis, 311 

Grocco 's sign in, 311 

pathology, clinical, 308 

physical signs, 310 

thorax in, 311 

visceral displacement in, 311 
sacculated, 307 
serofibrinous, 299 

Baccelli's sign in, 304 

decubitus in, 301 

diagnosis, 304 



Pleurisy, serofibrinous — Cont 'd. 
differential, 304 
egophony in, 304 
Ellis's curve in, 305 
Grocco 's sign in, 303 
mensuration in, 304 
pathology, clinical, 299 
physical signs, 301 
unilateral bulging in, 301 
visceral displacement in, 301 
Pleuritis, exudativa, 299 

sicca, 297 
Pleurodynia, 299 
Pleuropericarditis, 298, 410, 413 
Pleximeter, 112 
Plexor, 112 
Pneumonia, alba of fetus, 266 

apical, 234 

aspiration, 240 

catarrhal, 232 

central, 234 

clinical types, 234 

croupous, 232 

deglutition, 240 

disseminated, 242 

interstitial, chronic, 245 

lobar, 232 

lobular, 240 

massive, 234 

migratory, 234 

productive, 245 

pseudolobar, 242 

syphilitic, 268 
Pneumonic phthisis, acute, 252 
Pneumonokoniosis, 268 

clinical types, 269 

diagnosis, 272 

pathology, clinical, 268 

phthisis and, 271 

physical signs, 271 

sputum in, 271 
Pneumopericardium, 416 

diagnosis, 417 

pathology, clinical, 416 

physical signs, 417 
Pneumothorax, 314 

Biermer's phenomenon in, 316 

closed, 315 

coin test in, 316 

cracked-pot sound in, 316 

diagnosis, 316 

gutta cadens in, 316 

lung-fistula sound in, 316 

open, 315 

pathology, clinical, 314 

physical signs, 315 

succussion in, 316 

tympany in, 316 
Point, McBurney's, 539 

Signorelli 's, 576 

Valleix's, 25 



726 



INDEX 



Poliomyelitis, anterior, acute, 603 
Polypnea, 76 
Polysystole, 375 
Pomum Adami, 32 

displacement of, 32 
Portal vein, obstruction, 49G 

caput medusae in, 496 
Postdicrotic wave, 349 
PostpliaryngeaP abscess, 627 
Potain's sign, 365 
Potter's asthma, 271 
Pott 's disease, 634 
Poupart 's ligament, 486 
Power, muscular, 661 
Precordia, 326 

auscultation of, 366 

bulging of, 327 

inspection of, 327 

palpation of, 343 

percussion of, 359 

retraction of, 328 
Pregnancy, abdominal contour in, 

501 
Pressure, arterial, 396 

blood, 396 

diastolic, 397 

pulse, 397 

systolic, 397 

venous, 406 

instrumental estimation, 405 
Oliver 's method, 406 
Presystolic murmur, 382 

mitral, 383 

tricuspid, 388 

thrill, 345 
Prevost's sign, 681 
Productive pneumonia, 245 
Prolonged expiration, 77 

inspiration, 77 
Psoas abscess, 655 
Pterygoid thorax, 63 
Ptosis, of eyelid, 611 

of intestine, 506 

of liver, 568 

of stomach, 506 
Pubic sj)ine, 486 

symphysis, 486 
Puerile resx)iration, 154 
Pulmonary area, 367 
artery, 324 

circulation, 38 

congestion, 226 

incompetence, 457 

infarction, 229 
diagnosis, 231 
pathology, clinical, 229 
physical signs, 230 

insufficiency, 457 

murmur, 389 



Pulmonary - :spurmur — Cont 'd. 

diastolic, 390 

systolic, 389 
neoplasms, 295 

diagnosis, 296 

pathology, clinical, 295 

physical signs, 296 
osteoarthropathy, 641, 655 
regurgitation, 457 

diagnosis, 459 

pathology, clinical, 457 

physical signs, 457 

relative, 457 
sound, accentuation of, 370 

diminution of, 371 
stenosis, 459 

diagnosis, 461 
differential, 461 

pathology, clinical, 459 

physical signs, 460 

relative, 459 
syphilis, 266 
tuberculosis, 249 
valve, 320 
veins, 324 
Pulsations, abnormal, areas of, 85, 
328 
at base of heart, 85, 328 

of left lung, 85, 108 
at. left sternal border, 329 
at right sternal border, 329 
carotid, 331 
diastolic, 330 
epigastric, 330 
episternal, 329 
hepatic, 330 

localized, of thorax, 85, 108 
of jugular veins, 331 
of left axilla, 85 
of liver, 330 
sternal, 329 
systolic, 329 
supraclavicular, 330 
Pulse, 346 

allorrhythmic, 354 

analysis of, 350 

arterial, 346 

arterial changes in, 350 

bilateral symmetry of, 358 

capillary, 341, 636 

centripetal venous, 333, 342 

Corrigan, 357 

counting of, 347 

dicrotic, 356 

duration of, 356 

force of, 354 

hypertension of, 356 

hypotension of, 356 

in aortic regurgitation, 432 



INDEX 



727 



Pulse, in aortic regurgitation — Cont'd, 
stenosis, 439 

in bronchopneumonia, 242 

in cardiac dilatation, 477 
hypertrophy, 474 

in chronic adhesive pericarditis, 
415 
myocarditis, 470 

in lobar pneumonia, 235 

in mitral regurgitation, 447 
stenosis, 454 

in pulmonary regurgitation, 459 
stenosis, 460 

in serofibrinous pericarditis, 411 

in tricuspid regurgitation, 463 
stenosis, 465 

intermission of, 353 

paradoxical, 354 

pressure, 397, 401 
diminished, 402 
increased, 403 

rate of, 351 

disturbances of, 351 

rhythm of, 352 

taking, technic of, 346 

tension of, 356 

venous, 332 
centripetal, 333 

volume of, 354 

water-hammer, 357 
Pulsus alternans, 354 

bigeminus, 354 

celer, 357 

deficiens, 354 

durus, 356 

irregularis perpetuus, 379 

intercidens, 354 

intermittens, 354 

magnus, 354 

mollis, 356 

paradoxus, 354 

parvus, 354 

tardus, 356 

trigeminus, 354 
Puncture, of pleura, 174 
Pupil, Argyll-Eobertson, 679 

reflexes of, 678 
Pupillary unrest, 679 
Purpura hemorrhagica, 615, 625 
Purulent bronchitis, 208 

infiltration, 286 

pleurisy, 308 
Putrid bronchitis, 209 
Pyelography, 202 
Pyelonephrosis, 589 

fluctuation in, 593 
Pylorus, clinical anatomy, 520 

stenosis, 499, 525 



Pyopneumopericardium, 416 
Pyopneumothorax, 314 
Pyorrhea alveolaris, 621 

Q 

Quadrants, of abdomen, 492 
Quality, of murmurs, 382 

of percussion sound, 118 

of rales, 166 



E 

Rachitic rosary, 56, 66 

thorax, 64 
Eadial sphygmogram, 349 

variations in, 350 
Radiographic diagnosis, 176 
Eadiography, 176 
Eales, 159 

consonating, 162, 167 

crepitant, 162 

dry, 159 

in acute bronchitis, 206 

in bronchial asthma, 222 

in bronchiectasis, 218 

in bronchopneumonia, 243 

in chronic bronchitis, 211 

in emphysema, 277 

in fibrinous bronchitis, 214 

in lobar pneumonia, 236 

in phthisis, 262 

in pulmonary congestion, 227 
edema, 229 
infarction, 231 

in tracheobronchial stenosis, 225 

indux, 163, 236 

intensity of, 116 

moist, 159, 162 

mucous, 163 

number of, 164 

quality of, 166 

redux, 163, 236 

sibilant, 160 

size of, 165 

sonorous, 160 

time of, 166 

subcrepitant, 163 

uniformity of, 166 
Eanula, 625^ 
Rate, of pulse, 351 

of respiration, 73 
Eaynaud 's disease, 641 
Eays, roentgen, 176 
Eeaction, pupillary, Wernicke 's, 677 
Eecession, of thorax, expiratory, 72 
Eectum, clinical anatomy, 538 
Eecurrent endocarditis, 418 
Eeduplication, of sound, cardiac, 371 



728 



INDEX 



Eeiiex, accommodation, 679 
abdominal, 668 
arc, 66G 

cremasteric, 668 
Gordon's, 669 
Light, 678 

consensual, 679 
oculocardiac, 613 
Oppenlieim 's, 669 
patellar, 669 
plantar, 668 
tendo-Achilles, 671 
Eegion, axillary, 49 

contents of, 50 
epigastric, 492 

bulging of, 509 

contents of, 492 
hypochondriac, 49, 492 

bulging of, 509 

contents of, 492 
hypogastric, 492 

bulging of, 509 

contents of, 492 
infraaxillary, 50 

contents of, 50 
infraclavicular, 49 

contents of, 49 
infrascapular, 50 

contents of, 50 
interscapular, 50 

contents of, 50 
iliac, 492 

contents of, 492 
lumbar, 492 

contents of, 492 
mammary, 49 

contents of, 49 
scapular, 50 

contents of, 50 
sternal, 48 

contents of, 48 
supraclavicular, 48 

contents of, 48 
suprascapular, 50 

contents of, 50 
umbilical, 492 

bulging of, 509 

contents of, 492 
Eegions, of abdomen, 490 

of thorax, 46 
Regurgitation, aortic, 425 
mitral, 441 
pulmonary, 457 
tricusx)id, 462 
Relative dullness, 126 
Reptilian heart, 479 
Resistance, increase of, 119 
sense of, 118 



Resonance, .^mphoric, 141 
cracked-pot, 142 
impaired, 126 
money-chink, 142 
osteal, 121 
pulmonary, 119 

diminution at apices, 124 
of anterior borders, 125 
of lower borders, 125 

extension of anterior borders, 
125 
of lower borders, 125 

general decrease, 124 

increase, 124 

increased at apices, 124 

limits of, 123 

variations in, 123 
regional variations of, 119 
Skodaic, 139 
vesicular, 119 
vocal, 155 

absence of, 156 ' 

diminution of, 156 

increase of, 157 

modified, 158 
Respiration, absent, 154 
amphoric, 153 
Blot's, 78 
bronchial, 148 

intensity of, 150 

normal distribution, 149 

pathological variations, 153 

pitch of, 150 
bronchovesicular, 148 

normal distribution, 153 

pathological variations, 154 
cavernous, 153 
character of, 73 
Cheyne-Stokes, 78 
cogwheel, 154 
costal, 74 
costoabdominal, 74 
frequency of, 73 . 
in apoplexy, 77 
in bronchial asthma, 77 
in cerebral abscess, 77 

hemorrhage, 77 

tumor, 77 
in diabetes mellitus, 77 
in edema of glottis, 78 
in emphysema, 77 
in laryngeal stenosis, 77 
in laryngismus stridulus, 77 
in lobar pneumonia, 77 
in meningitis, 77, 79 
in phthisis, 77 

in pleurisy with effusion, 77 
in postpharyngeal abscess, 77 
in quinsy, 77 



INDEX 



729 



Eespiration — C'oiit 'd. 

in tonsillar liypertrox^liy, 77 

in uremia, 77 

meningeal, 78 

movements of, 72 

normal, 72 

pathological variations, 76 

phases of, 72 

prolonged expiration, 77, 154 
insi)iration, 77 

puerile, 154 

rapid, 76 

slow, 77 

sterterous, 77 

stridulous, 78 

upper thoracic, 74 

vesicular, 151 

normal distribution, 151 
pathological variations, 154 
Eespiratory arrhythmia, 375 

organs, diseases of, 205 
examination of, 52 
percussion of, 117 
Eetraction, of abdomen, 510 

of head, 602 

precordial, 327 

systolic, of thorax, 333 

unilateral, of thorax, 70 
Ehagades, 617 
Ehonchal fremitus, 102 
Ehonchi, 159 
Ehythm, canter, 371 

gallop, 371 

of pulse, 352 
Eibs, as landmarks of thorax, 44 

course of, 60, 64 

incurvation of, 56 

method of counting, 45 

nodules of, 108 

obliquity of, 56, 60 64 

overlapping of, 56 

prominence of, 56, 64 

tenderness of, 107 
Eickets, 599 

bowing of tibiae in, 655 

bow-legs in, 655 

epiiohyseal swelling in, 647 

funnel chest in, 68 

Harrison's sulcus in, 67 

head of, 599 

keel-breast in, 68 

knock-knees in, 655 , 

rosary in, 56, 599 

thorax of, 64 
Eiedel's lobe, 552 
Eight auricle, clinical anatomy, 318 

ventricle, 319 
Eigidity, of abdominal wall, 513 

of rectus, 513 



Einia glottidis, 33 

Eiva-Eocci sphygmomanometer, 397 

Eoentgenogram, in aneurysm, aortic, 
201 
in bronchopneumonia, 196 
in chronic interstitial pneumonia, 

196 
in lobar pneumonia, 196 
in mediastinal neoplasm, 198 
in pericarditis, 200 
in pleural thickening, 197 
in pleurisy with effusion, 197 
in pneumothorax, 198 
in pulmonary neoplasm, 197 
syphilis, 194 
abscess, 196 
gangrene, 196 
in tuberculosis, pulmonary, 191 
of diaphragm, 191 
of heart, 199 
of thorax, 188 
of urinary tract, 201 

Eoentgenography, 188 

Eoentgen rays, 188 

Eogers' sphygmomanometer, 402 

Eomberg 's sign, 659 

Eosary, rachitic, 56 

Eose spot, 496 

Eot, grinder's, 271 

Eotch's sign, 411 

Eothschild's sign, 260 



Saccular bronchiectasis, 215 
Sacculated pleurisy, 307 
Saddle nose, 614 
Safety-valve murmur, 462 
Salmon patches, 614 
Sarcoma, of kidney, 593 

of lung, 295 
Scaphoid abdomen, 510 
Scapula, angle of, 45 

as landmark of thorax, 45 

alar, 63 

mobile, 63 

winged, 35, 63 
Scapular line, 46 
spinal, 47 

region, 50 

contents of, 50 
Scarpa's triangle, bulging in, 655 
Scars, of abdomen, 655 

of forehead, 611 

of neck, 635 

of thorax, 54 
Sclera, blue, 614 

yellow, 614 
Scleritis, 614 

Sclerosis, amyotrophic lateral, 643, 
670 



730 



INDEX 



Sclerosis — Cont 'd. 

multiple, 644 
hand of, 643 
tremor of, 644 
Scoliosis, 45, 66, 69 
Scotoma, 676 

absolute, 677 

relative, 677 
Scratching percussion, 529 
Scrobiculus cordis, 44 
Seal-fin hand, 644 

Semilunar space of Traube, 130, 520, 
530, 582 

valves, 320 
Sensation, muscular, 666 

pain, 665 

pressure, 664 

stereognostic, 666 

tactile, 663 

temperature, 664 
Septa, cardiac, 479 
absence of, 479 

interauricular, 479 

interventricular, 479 
Serofibrinous pericarditis, 410 

pleurisy, 299 
Shock, valve, 343 

aortic, 343 

diminished, 343 

increased, 343 

pulmonary, 343 
Sibilant rales, 160 
Sibson's fascia, 28 
Siderosis, 269 

Sigmoid flexure, clinical anatomy, 
537 

palpation of, 542 
Sign, Abadie 's, 610 

Auenbrugger 's, 411 

Babinski's, 669 

Baccelli's, 157 

Bamberger 's, 412 

Biermer's, 139 

Broadbent's, 333, 414 

Duroziez's, 395 

Erni's, 262 

Ewart's, 411 

Friedreich's, 137, 331, 414 

Gerhardt's, 138 

Glenard's, 520 

Grocco's, 129 

Kernig 's, 652 

Kussmaul 's, 414 

Litten's, 75 

Lorenz's, 260 

Oliver's, 34, 483, 631 

Potain's, 365 

Prevost's, 681 

Eomberg's, 659 

Botch's, 411 



Sign— Cont '^1. 

Eothschild's, 260 
Von Graeffe's, 613 
Williams', 191 
Wintrich's, 135 
Signorelli's point, 576 
Simple arrhythmia, 374 

endocarditis, 418 
Sinus, complementary, 41 
node, 321 
of Valsalva, 320 
venosus, 318 
Sixth costal line, 47 
Skin, of abdomen, 495 
color of, 496 
eruptions of, 496 
scars of, 495 
of thorax, 53 
eruptions of, 54 
pigmentation of, 53 
striae of, 54 
Skodaic resonance, 139 
in bronchopneumonia, 243 
in lobar pneumonia, 235 
in serofibrinous jiericarditis, 140 
pleurisy, 302 
Skull, fracture of, 179, 604 
Smoker's patch, 624 
Snoring respiration, 77 
Sonorous rales, 160 
Souffle, umbilical, 518 

uterine, 518 
Sound, aortic, accentuation of, 369 
diminution of, 370 
cracked-pot, 142 
deglutition, 532 
falling-droj), 167 

friction, pericardial, 344, 393, 409 
perihepatitic, 516 
perisplenitic, 516, 577 
peritoneal, 516, 577 
pleural, 169 
lung-fistula, 171 

in hydropneumothorax, 171 
mitral, accentuation of, 369 

diminution of, 369 
percussion, 118 
abnormal, 126 
amphoric, 141 
attributes of, 118 
Biermer 's, 139 
change of, Friedreich's, 137 
Gerhardt's, 138 
Wintrich's, 135 
cracked-pot, 142 
dull, 128 
duration of, 118 
flat, 130 . 
Gairdner's, 144 



INDEX 



731 



Sound, percussion — Cont 'd. 

hyperresonant, 130 

impaired, 126 

intensity of, 118 

interrupted, of Wintrich, 135 

normal, 119 

pitch of, 118 

quality of, 118 

resonant, 119 
pulmonary, accentuation of, 370 

diminution of, 371 
splashing, 168 
suceussion, 526, 532 

pericardial, 393 
tracheal, of Williams, 141 
Sounds, adventitious, 159, 380 
cardiac, 366 

accentuation of, 368 

diminution of, 368 

reduplication of, 371 
endocardial, 380 
exocardial, 380 
extraneous, 145 
respiratory, 148 

abnormal, 153 

normal, 148 
Space, Traube 's semilunar, 130, 520, 
■ 528, 582 

borders of, 528 

dullness of, 130 
Spaces, intercostal, 25, 44, 61, 107 
bulging of, 55 
narrowing of, 55 
retraction of, 55, 61, 84 
tenderness of, 107 
widening of, 55, 61, 64 
Spade-hand, 641 
Spasm brachial, 610 
choreic, 610 
clonic, unilateral, 611 
facial, 610 
habit, 610 
lingual, 622 
nodding, 603 
professional, 645 
tetanic, 610 
Spastic gait, 659 
Sphygmogram, arterial, 349 
clinical significance, 349 
variations in, 350 
Sphygmomanometer, Cook 's, 397 
Erlanger's, 399 
Faught's, 403 
Janeway's, 400 
Riva-Rocci's, 397 
Rogers', 402 
Stanton's, 398 
Sphygmomanometry, auscultatory 
method, 401 
palpatory method, 399 



Sphygmomanometry — Cont 'd. 

technic of, 399 
Spine, deformity of, 487 

iliac, 487 
Spirals, Curschmann's, 219 
Splashing sounds, 168, 526, 532 

gastric, 526, 532 

pericardial, 393 

j^leural, 168 
Spleen, amyloid, 576 

clinical anatomy of, 570 

consistence of, 576 

displacement of, 578 

dullness of, 582 

enlargement of, 573 

examination of, 572 

floating, 577 

inspection of, 572 

mobility of, 572 

palpation of, 574 

percussion of, 578 

point, Signorelli's, 576 

surface markings of, 571 

tenderness of, 576 
Splenohepatic angle, 579 
Splenopulmonary angle, 578 
Sx^lenorenal angle, 578 
Spots, cold, 664 

heat, 664 

Koplik's, 626 

milk, 410 
Sputum, in bronchial asthma, 219 

in bronchiectasis, 216 

in bronchopneumonia, 242 

in chronic ulcerative phthisis, 261 

in lobar pneumonia, 233 

in pulmonary abscess, 287 
edema, 228 
gangrene, 292 
infarction, 230 
Squint, 680 

Stanton's sphygmomanometer, 398 
Staphyloma, 614 
Station, 659, 686 
Stenosis, aortic, 434 

mitral, 451 

of bronchi, 224 

of trachea, 224 

pulmonary, 459 

tricuspid, 465 
Sternal line, 46 

pulsation, 329 

region, 48 

contents of, 48 
Sternomastoids, prominence of, 63, 

629 
Sternum, as landmark of thorax, 44 

length of, 44 

prominence of, 44, 68, 108 

tenderness of, 108 



732 



INDEX 



Sterterous respiration, 77 
Stethoscope, 145 

binaural, 145 

Bowles, 145 

monaural, 145 

selection of, 145 
Stokes-Adams disease, 377 
Stomach, auscultation of, 532 

auscultatory percussion of, 529 

clinical anatomy of, 520 

fundus of, 520 

greater curvature of, 520 

hourglass, 531 

inflation of, 523 

inspection of, 521 

lesser curvature of, 520 

orifice, cardiac, 520 
pyloric, 520 

palpation of, 524 

percussion of, 524 

peristalsis of, 525 

pit of, 44 

relations of, 520 

succussion sounds of, 520, 532 

surfaces of, 620 

tenderness of, 524 

tumor of, 524 

tympany of, 521, 530 
decreased, 531 
increased, 530 
Stomatitis, catarrhal, 626 

gangrenous, 626 

ulcerative, 621 
Stone-cutter's phthisis, 271 
Strabismus, 680 
Striae, of abdomen, 495 

of thorax, 54 
Stridulous respiration, 78 
Subclavian artery, auscultation of, 
394 

murmur in, 394 
Subcostal angle, 57 

line, 491 
Subcrepitant rale, 163 
Submaxillary nodes, enlarged, 632 
Succussion, 168, 169, 393 

fremitus, 104 

Hippocratic, 168 

j)ericardial, 393 

sound, 168 
Sulcus, Harrison 's, 67 
Supraclavicular fossa, 44 

X^ulsation, 330 

region, 48 

contents of, 48 
Suprascapular fossa, 50 

region, 50 

contents of, 50 



Suprasternal notch, 44 

pulsation in, 329 
Surface markings, of aorta, thoracic, 
326 
abdominal, 489 
of bronchi, 42 
of cardiac valves, 326 
of common iliac artery, 489 

vein, 489 
of deep epigastric artery, 489 
of external iliac artery, 489 

vein, 489 
of heart, 324 
of intestine, large, 535 

small, 532 
of kidneys, 585 
of liver and gall bladder, 553 
of lungs, 41 
of pancreas, 544 
of pleura, 39 
of pulmonary artery, 326 
of sx)leen, 571 
of stomach, 520 
of trachea, 42 
Sutures, open, 600 
Symmetry, of pulses, 358 
Symphysis pubis, 486 
Syphilis, pulmonary, 266 
acquired, 266 
congenital, 266 
pathology, clinical, 266 
physical signs, 267 
Syphilitic bronchopneumonia, 267 
fibrosis of lung, 267 
periostitis, 647 
Systolic jugular pulsation, 331 
murmurs, 382 
aortic, 384 
arterial, 394 
mitral, 384 
pulmonary, 389 
tricuspid, 387 
pressure, 397 
pulsation, epigastric, 330 
retraction, of thorax, 333 
venous pulse, 333 



Tabes mesenterica, 534 
Tachycardia, 375 

essential, 375 

paroxysmal, 376 

reflex, 375 
Talipes, 651 

equinus, 651 

valgus, 651 

varus, 651 
Teeth, delayed, 620 

early decay, 620 



INDEX 



733 



Teeth— Cont 'd. 

examination of, 620 

grinding of, 621 

Hutchinson's, 621 

loosening of, 620 

premature, 620 
Tenderness, of abdomen, 513, 524 
points of, 513 

of epigastrium, 524 

of kidney, 589 

of spleen, 576 

of thorax, 105 
Tension, of pulse, 356 
Test, anvil, 144 

Barany's, 685 

caloric, 69'3 

coin, 144 

Gairdner 's, 144 

in pneumothorax, 144 

Holmgren, 675 

pointing, 686 

rotation, 687 

Thomson's, 676 
Tetanus, 602, 610 

risus sardonicus in, 610 
Tetany, hand of, 644 
Thigh, edema of, 653 

examination of, 653 

tumor of, 654 
Third costal line, 47 
Thomson's test, 676 
Thoracentesis, 174 
Thoracometry, 173 

Thorax, abnormalities of expansion, 
82 

alar, 63 

auscultation of, 145 

bilateral deformities of, 60 

bony, 25, 58 

cavity of, 28 

clavicles, as landmarks of, 44 

clinical anatomy of, 25 

contour of, 60, 65 

crepitation, 105 

deformities of, 59, 60, 70, 71 
acquired, 59 
bilateral, 60 
congenital, 59 
local, 71 
unilateral, 70 

diminution, unilateral, 70 

divisions of, 29 

edema of, 55 
general, 55 
local, 55 

elongation of, 63 

emphysematous, 60 

enlarged veins of, 54 

enlargement, unilateral, 70 



Thorax, enlargement — Cont 'd. 

local, 71 
eruptions of, 54 
examination of, 52 
expansion of, 82, 88 

general decrease, 82 
increase, 82 

local variations, 83 

unilateral decrease, 83 
increase, 82 
expiratory type of, 57 
flat, 63 

fluctuation of, 108 
funnel, 68 
inlet of, 44 
inspection of, 52 
inspiratory type of, 57 
intercostal spaces as landmarks, 44 
landmarks of, 44 
lines of, 46 
local deformities of, 70 

enlargement of, 70 

retraction of, 71 
localized pulsations of, 85, 108 
mammary gland as landmark, 45 
mensuration of, 173 
movements of, 72 

frequency of, 73 

rhythm of, 78 
musculature of, 54 

wasting of, 54 
nipples as landmarks, 44 
normal, 56 

cross-section of, 58 

landmarks of, 44 
of child, 58 

cross-section of, 58 
palpation of, 86, 343 
paralytic, 63 
percussion of. 111 

deep, 117 

superficial, 117 
phthisical, 63 
pigeon, 68 

cross-section of, 68 
pigmentation of, 53 
pterygoid, 63 
pulsation of, 85 
rachitic, 64 

cross-section of, 68 
radiography of, 188 
regions of, 46 
ribs as landmarks of, 44 
scapulae as landmarks of, 45 
scars of, 53 
shape of, 56 
size of, 56 
skin of, 53 
spine as landmark of, 45 



734 



INDEX 



Thorax— Cont'd. 

sternum as landmarks of, 44 

strise of, 54 

subcutaneous tissues of, 54 

surface of, 54 

systolic retraction of, 333, 341 

tenderness of, 105 

thickness of, 28 

unilateral contraction of, 70 
deformities of, 70 
enlargement of, 70 

veins of, 54 

vibrations of, 89 

wall, 28 
Thrill, 344 

at apex, 345 

at aortic area, 345 

at base of heart, 345 

at pulmonary area, 346 

at tricuspid area, 346 

cardiac, 344 

diastolic, 344 

hemic, 344 

in aortic aneurysm, 345 

in mitral stenosis, 345 

intensity of, 344 

presystolj^c, 344 

quality of, 345 

systolic, 344 

vascular, 344 
Thrush, 625 
Thyroid gland, abscess of, 632 

atrophy of, 632 

enlargement of, 631 

fluctuation of, 631 

murmur over, 631 

palpation of, 631 

thrill over, 631 
Tic, convulsive, 610 
Tinkle, metallic, 167 

in pneumothorax, 316 
Tinnitus, 685 
Toes, examination of, 650 

gangrene of, 650 

in gout, 650 

perforating ulcer of, 650 
Tone, tracheal, Williams ', 141 
Tongue, atrophy of, 621 

color of, 625 

cysts of, 625 

dryness of, 625 

examination of, 621 

geographical, 624 

hypertrophy of, 621 
acquired, 621 
congenital, 621 

indentations of, 625 

in pellagra, 625 

leukoplakia, 624 



Tongue— Cont 'd. 

movements of, 622 

paralysis of, 622 

size of, 621 

smoker 's patch, 624 

spasm of, 622 

strawberry, 626 

thrush, 625 

tremor of, 622 

ulceration of, 622 
Tonsillitis, follicular, 627 
Tonsils, enlargement of, 628 

examination of, 627 

inflammation of, 627 

pseudomembrane on, 628 

ulceration of, 628 
Tophi, 604, 638 
Torticollis, congenital, 629 

rheumatic, 602 

spasmodic, 603, 629 
Tortuosity, of abdominal veins, 496 

of thoracic veins, 54 
Toxemic dyspnea, 80 
Tracheal tone, Williams', 141 

tug, 34, 483, 631 
Trachea, bifurcation of, 33 

clinical anatomy of, 33 

deflection of, 629 

movements of, 631 

surface markings of, 42 
Traehealis muscle, 33 
Tracheobronchial stenosis, 224 

diagnosis, 225 

pathology, clinical, 225 

X^hysical signs, 224 

resx)iration in, 77 
Tracheophony, 156 
Tract, gastrointestinal, radiography 
of, 203 

urinary, radiography of, 201 
Traube 's semilunar space, 130, 520. 
530, 582 

borders of, 528 
gastrocardiac, 528 
gastrocolic, 528 
gastrohepatic, 528 
gastropulmonary, 528 

decrease of, 531 

dullness of, 130 

increase of, 530 
Tremor, convulsive, 662 

intention, 644, 662 

of hand, 644 

of tongue, 622 

pill-rolling, 644, 662 ' 
Trichinosis, 611 
Tricuspid area, 367 

incompetence, 462 



INDEX 



735 



Tricuspid area — Cont 'd. 
insufficiency, 4G2 
regurgitation, 462 
diagnosis, 464 
jDathology, clinical, 462 
physical signs, 463 
pulse in, 464 
relative, 462 
murmur, 387 
presystolic, 388 
systolic, 388 
stenosis, 465 
diagnosis, 466 
pathology, clinical, 465 
X3hysical signs, 465 
valve, 320 

anatomic site, 367 
auscultatory area, 367 
Trismus, 682 
Tubercle, miliary, 250 
Tuberculopneumonic phthisis, acute, 

250 
Tuberculosis, pulmonary, 249 
of bone, 183 
of vertebrae, 183, 627 
Tug, tracheal, 34, 483, 631 
Tumor, intraabdominal 515 
of arm, 647 
of kidney, 593 
of liver, 559 
of intestine, small, 534 
of stomach, 524 
pulmonary, 295 
diagnosis, 296 
pathology, clinical, 295 
physical signs, 296 
Turgescence, jugular, 331 
Tussile fremitus, 104 
Twelfth dorsal line, 47 
Tympanites, abdominal contour in, 

503 
Tympany, 130 
bell, 144 
colonic, 542 
gastric, 521, 527 
decrease of, 531 
increase of, 530 
intensity of, 132 
intestinal, 534 
in ascites, 75 

in bronchiectatic cavities, 132 
in pneumothorax, 132 
in pulmonary cavities, 132 
laws governing, 113 
on percussion, 130 
pitch of, 132 
Skoda 's 139 
Typhilitis, 539 



U 

Ulcer, carcinomatous, 615, 624 

corneal, 614 

of leg, 651 

nasal, 615 

perforating, of foot, 650 

simple, 622 

syphilitic, 615, 623 

tuberculous, 615, 623 
Ulceration, of intestine, 539 

peritonsillar, 628 

pharyngeal, 627 
Umbilical hernia, 497 _, 

notch, 549 

region, 492 

contents of, 492 

souffle, 518 
Umbilicus, as landmark of abdomen, 
487 

eruptions of, 495 

inflammation of, 496 

protrusion of, 496 

retraction of, 496 
Unilateral bulging of thorax, 70 

retraction of thorax, 70 
Unrest, pupillary, 679 
Ureters, examination of, 597 

palpation of, 598 

surface markings of, 598 

tenderness of, 598 
Uremia, breath in, 620 
Urinary tract, radiography of, 201 
Uterine souffle, 518 
Uvula, elongation of, 627 



Valsalva, sinus of, 320 
Valve, aortic, 320, 326 
anatomic site, 326 
auscultatory area, 367 

areas, 367 

ileocecal, 534 

mitral, 320, 326, 367 
anatomic site, 326 
auscultatory area, 367 

pulmonary, 320, 326 
anatomic site, 326 
auscultatory area, 368 

shock, 343 

tricuspid, 320, 326 
anatomic site, 326 
auscultatory area, 367 
Valves, cardiac, 320, 326 
diseases of, 418 

of heart, 320, 326 
perforation of, 426 
Valvular disease, chronic, 423 
effects of, 423 
incidence of, 423 



736 



INDEX 



Valvular— Cont 'd. 

endocarditis, 418 
Varicose veins, 651 
Vascular dullness, 365 

murmurs, 394 
Vegetations, adenoid, 615 
Vein, common iliac, surface mark- 
ing, 489 
external iliac, surface marking, 

489 
portal, obstruction of, 496 
caput medusae in, 496 
Veins, cervical, engorgement of, 331 
distended, of abdomen, 496 

of thorax, 54 
fluid, 380 

jugular, diastolic collapse of, 331 
pulsation of, 331 
engorgement of, 331 
pulmonary, 324 
varicose, 651 
Vena azygos major, 34 
Vena cava, 324 

inferior, surface marking, 489 
superior, 324 
Venous hum, 395 
murmurs, 395 
pressure, 406 
pulse, auricular, 332 
centripetal, 333 
negative, 332 
physiologic, 332 
positive, 332 
presystolic, 332 
systolic, 333 
Ventricle, left, clinical anatomy, 319 
dilatation of, 476 
hypertrophy of, 472 
right, clinical anatomy of, 319 
dilatation of, 477 
hypertrophy of, 477 
Vermiform appendix, 535 

palpation of, 538 
Vertebrae, deformity of, 69 

method of counting, 45 
Vertiginous gait, 661 
Vertigo, 685 
induced, 689 
spontaneous, 687 
Vesicular resonance, 119 
respiration, 151 
intensity, 152 
pitch, 153 
Vibrations, thoracic, 89 
Vincent 's angina, 628 
Viscera, abdominal, clinical anatomy 
of, 485 
examination of, 485 
thoracic, clinical anatomy of, 31 
examination of, 52 



Visceral pj^eura, 30 

Visceroptosis, abdominal contour in, 

506 
Vision, acuity, 675 

color, 675 

field of, 676 
Vocal fremitus, 89 

absence of, 101 

decrease of, 99 

increase of, 98 

intensity of, 91 

normal variations of, 94 
Vocal resonance, 155 

absence of, 156 

decrease of, 156 

increase of, 157 

modified, 158 
Voice, cavernous, 158 
Volume, of pulse, 354 
Volvulus, 534 
Von Graeffe 's sign, 613 



W 

Wall, abdominal, 511 
edema of, 513 
palpation of, 511 
rigidity of, 513 
suppuration of, 513 
tenderness of, 513 
thickness, estimation of, 511 
arterial, 350 

changes in, 350 
thoracic, 25, 28 
Water-hammer pulse, 357 
Wave, dicrotic, 349 
fat, 514 
fluid, 513 
post-dicrotic, 349 
Wavy expansion, 84 
Wernicke's reaction, 677 
Whispering pectoriloquy, 157 
White spots, of nails, 636 
Whitlow, 638 
Williams' sign in j)hthisis, 191 

tracheal tone, 141 
Winged scapulae, 45, 63 
Wintrich's change of sound, 135 

interrupted, 135 
Woillez's disease, 239 
Woody phlegmon, 635 
Wrist-drop, 644 
Wry-neck, 602 



Xanthelasma, 625 

Xanthoma, 611 

Xerostomia, 626 

X-ray, 176 {see Koentgen rays) 



